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Carabotti M, Sgamato C, Amato A, Beltrame B, Binda GA, Germanà B, Leandro G, Pasquale L, Peralta S, Viggiani MT, Severi C, Annibale B, Cuomo R. Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease. Dig Liver Dis 2024:S1590-8658(24)00841-7. [PMID: 39004551 DOI: 10.1016/j.dld.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.
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Affiliation(s)
- Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Costantino Sgamato
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
| | | | - Benedetta Beltrame
- Department of Technical-Health Care Professions Dietetics Unit- AUSL Toscana Centro Santa Maria Nuova Hospital, Italy
| | | | - Bastianello Germanà
- Gastroenterology and Digestive Endoscopy San Martino Hospital, Belluno, Italy
| | | | - Luigi Pasquale
- Gastroenterology and Digestive Endoscopy, Avellino, Italy
| | - Sergio Peralta
- UOS Diagnostic and Interventional Digestive Endoscopy AOU Policlinico P.Giaccone, Palermo, Italy
| | | | - Carola Severi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
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Perrone G, Giuffrida M, Tarasconi A, Petracca GL, Annicchiarico A, Bonati E, Rossi G, Catena F. Conservative management of complicated colonic diverticulitis: long-term results. Eur J Trauma Emerg Surg 2023; 49:2225-2233. [PMID: 35262746 DOI: 10.1007/s00068-022-01922-1] [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: 09/29/2021] [Accepted: 02/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. AIM To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. METHODS This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. RESULTS We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). CONCLUSIONS Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.
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Affiliation(s)
- Gennaro Perrone
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Mario Giuffrida
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | | | - Alfredo Annicchiarico
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Elena Bonati
- General Surgery Unit, Department of Medicine and Surgery, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Giorgio Rossi
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Parma University Hospital, Parma, Italy
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Cirocchi R, Duro F, Avenia S, Capitoli M, Tebala GD, Allegritti M, Cirillo B, Brachini G, Sapienza P, Binda GA, Mingoli A, Fedeli P, Nascimbeni R. Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review. J Clin Med 2023; 12:5522. [PMID: 37685590 PMCID: PMC10488020 DOI: 10.3390/jcm12175522] [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: 07/01/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses. MATERIAL AND METHODS A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. CONCLUSIONS Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Francesca Duro
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Stefano Avenia
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Matteo Capitoli
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | | | | | - Bruno Cirillo
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Paolo Sapienza
- Department of Surgery, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy;
| | | | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | | | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy;
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: 10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: https:/doi.org/10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Abdalla TSA, Zimmermann M, Weisheit L, Thomaschewski M, Deichmann S, Nolde J, Keck T, Benecke C. Long-term functional outcome after tubular laparoscopic sigmoid resection for diverticular disease. Int J Colorectal Dis 2023; 38:14. [PMID: 36645511 PMCID: PMC9842559 DOI: 10.1007/s00384-023-04311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE Sigmoid resection for diverticular disease is a frequent surgical procedure in the Western world. However, long-term bowel function after sigmoid resection has been poorly described in the literature. This study aims to assess the long-term bowel function after tubular sigmoid resection with preservation of inferior mesenteric artery (IMA) for diverticular disease. METHODS We retrospectively identified patients who underwent sigmoid resection for diverticular disease between 2002 and 2012 at a tertiary referral center in northern Germany. Using well-validated questionnaires, bowel function was assessed for fecal urgency, incontinence, and obstructed defecation. The presence of bowel dysfunction was compared to baseline characteristics and perioperative outcome. RESULTS Two hundred and thirty-eight patients with a mean age of 59.2 ± 10 years responded to our survey. The follow-up was conducted 117 ± 32 months after surgery. At follow-up, 44 patients (18.5%) had minor LARS (LARS 21-29) and 35 (15.1%) major LARS (LARS ≥ 30-42), 35 patients had moderate-severe incontinence (CCIS ≥ 7), and 2 patients (1%) had overt obstipation (CCOS ≥ 15). The multivariate analysis showed that female gender was the only prognostic factor for long-term incontinence (CCIS ≥ 7), and ASA score was the only preoperative prognostic factor for the presence of major LARS at follow-up. CONCLUSION Sigmoid resection for diverticular disease can be associated with long-term bowel dysfunction, even with tubular dissection and preservation of IMA. These findings suggest intercolonic mechanisms of developing symptoms of bowel dysfunction after disruption of the colorectal continuity that are so far summarized as "sigmoidectomy syndrome."
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Affiliation(s)
- Thaer S A Abdalla
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany.
- Department of General Surgery, University Medical Center Schleswig Holstein, Campus Lübeck, Ratzeburger Alle 160, 23564, Lübeck, Germany.
| | - Markus Zimmermann
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
- Department of General Surgery, University Medical Center Schleswig Holstein, Campus Lübeck, Ratzeburger Alle 160, 23564, Lübeck, Germany
| | - Lena Weisheit
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
| | - Michael Thomaschewski
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
| | - Steffen Deichmann
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
| | - Jan Nolde
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
| | - Tobias Keck
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany
| | - Claudia Benecke
- Department of General Surgery, at the University Medical Center Schleswig Holstein, 23562, Lübeck, Germany.
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Liu Y, Chen Z, Dou L, Liu S, Zhang Y, Liu Y, Wang G. Endoscopic therapy of anastomotic diverticulum combined with stercorolith incarceration: A case report. Front Med (Lausanne) 2022; 9:1053487. [PMID: 36523774 PMCID: PMC9745778 DOI: 10.3389/fmed.2022.1053487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 08/30/2023] Open
Abstract
Diverticulosis is a commonly acquired disease of the lower gastrointestinal tract, which may be associated with significant morbidity and adverse effects on quality of life. Although several national guidelines focused on the treatment of diverticulosis, multiple controversies remained regarding the disease management of diverticulosis. For some controversial issues, such as the role of antibiotics in mild diverticulitis, when and how to operate on patients with acute diverticulitis, there is no conclusion yet. To our knowledge, this is the first report of endoscopic therapy for anastomotic diverticulitis caused by stercorolith incarceration. In the current case, a 49-year-old woman complained of recurrent subumbilical pain without obvious inducement for half a year. Colonoscopy showed anastomotic diverticulum combined with stercorolith incarceration. After local inflammation relieved by conservative treatment, the patients received endoscopic mucosal incision and lithotomy. Then the diverticulum was closed with titanium clips. The abdominal pain of patient was completely relieved, and the reexamination of colonoscopy showed that the wound healed well after 1 year of follow-up. This case suggests that for anastomotic diverticulitis caused by stercorolith incarceration, endoscopic therapy can remove the stimulation factors better and avoid the recurrence and progression of the disease compared with conservative treatment. Moreover, endoscopic therapy achieves the maximum in minimally invasive surgery and reduces complications and surgical costs compared with radical surgery.
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Affiliation(s)
- Yi Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihao Chen
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lizhou Dou
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyao Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueming Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Leifeld L. German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis, epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification. United European Gastroenterol J 2022; 10:923-939. [PMID: 36411504 PMCID: PMC9731664 DOI: 10.1002/ueg2.12309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
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Affiliation(s)
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikum DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐KrankenhausSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg P. Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas Schreyer
- Institut für Diagnostische und Interventionelle RadiologieBrandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
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GOUVAS N, AGALIANOS C, MANATAKIS DK, PECHLIVANIDES G, XYNOS E. Elective surgery for conservatively treated acute uncomplicated diverticulitis: a systematic review of postoperative outcomes. Minerva Surg 2022; 77:591-601. [DOI: 10.23736/s2724-5691.22.09726-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kim YS. [Diagnosis and Treatment of Colonic Diverticular Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 79:233-243. [PMID: 35746837 DOI: 10.4166/kjg.2022.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/29/2022] [Indexed: 06/15/2023]
Abstract
Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.
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Affiliation(s)
- You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable. OBJECTIVES The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery. SEARCH METHODS For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021. SELECTION CRITERIA Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method. MAIN RESULTS The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information. For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited. AUTHORS' CONCLUSIONS The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.
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Affiliation(s)
- Marie-Louise Dichman
- Department of Surgical Gastroenterology , Hvidovre University Hospital, Copenhagen, Denmark
| | - Steffen Jais Rosenstock
- Department of Surgical Gastroenterology , Hvidovre University Hospital , Copenhagen, Denmark
| | - Daniel M Shabanzadeh
- Department of Surgical Gastroenterology , Hvidovre University Hosipital , Copenhagen, Denmark
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12
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Vaghiri S, Jagalla DM, Prassas D, Knoefel WT, Krieg A. Early elective versus elective sigmoid resection in diverticular disease: not only timing matters-a single institutional retrospective review of 133 patients. Langenbecks Arch Surg 2022; 407:1613-1623. [PMID: 35194650 PMCID: PMC9283160 DOI: 10.1007/s00423-022-02464-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
Purpose The optimal timing of elective surgery in patients with the colonic diverticular disease remains controversial. We aimed to analyze the timing of sigmoidectomy in patients with diverticular disease and its influence on postoperative course with respect to the classification of diverticular disease (CDD). Methods Patients who underwent elective laparoscopic sigmoidectomy were retrospectively enrolled and subdivided into two groups based on the time interval between the last attack and surgery: group A, early elective (≤ 6 weeks), and group B, elective (> 6 weeks). Multivariate regression models were used to identify factors which predict conversion to laparotomy, postoperative course, and length of hospital stay. Results A total of 133 patients (group A (n = 88), group B (n = 45)) were included. Basic demographic data did not differ between groups except for a higher rate of diabetes in group B (p = 0.009). The conversion rate was significantly higher in group A in comparison to group B (group A vs. group B: n = 23 (26.1%) vs. n = 3 (6.7%), p = 0.007). Logistic regression analysis revealed the timing of surgery and CDD stage as significant predictors for intraoperative conversion. Moreover, the postoperative course was influenced by high age as well as intraoperative conversion and length of hospital stay by conversion, preoperative CRP levels, and elective surgery. Conclusions Both, timing of surgery and the disease stage, influence the conversion rates in laparoscopic sigmoidectomy for diverticular disease. Accordingly, patients with complicated acute or chronic sigmoid diverticulitis should be operated in the inflammation-free interval. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02464-1.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - David Mario Jagalla
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany.
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Moorenstr. 5, Bldg. 12.46, 40225, Duesseldorf, Germany.
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13
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Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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14
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Hoffmann JC, Trimborn CP, Hoffmann M, Schröder R, Förster S, Dirks K, Tannapfel A, Anthuber M, Hollerweger A. Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology. Int J Colorectal Dis 2021; 36:2347-2360. [PMID: 34143276 DOI: 10.1007/s00384-021-03940-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm. METHODS Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database. RESULTS Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA. CONCLUSION Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany.
| | - Claus-Peter Trimborn
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany
| | - Michael Hoffmann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ralf Schröder
- Radiologische Klinik, St. Marien- und St. Annastiftskrankenhaus Ludwigshafen, Ludwigshafen, Germany
| | - Sarah Förster
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Klaus Dirks
- Gastroenterologie, Allgemeine Innere Medizin und Geriatrie, Rems-Murr-Kliniken Winnenden, Winnenden, Germany
| | - Andrea Tannapfel
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Matthias Anthuber
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Alois Hollerweger
- Abteilung für Radiologie und Nuklearmedizin Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Austria
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15
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Ripollés T, Sebastián-Tomás JC, Martínez-Pérez MJ, Manrique A, Gómez-Abril SA, Torres-Sanchez T. Ultrasound can differentiate complicated and noncomplicated acute colonic diverticulitis: a prospective comparative study with computed tomography. Abdom Radiol (NY) 2021; 46:3826-3834. [PMID: 33765176 DOI: 10.1007/s00261-021-03060-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/06/2021] [Accepted: 03/10/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To prospectively assess the diagnostic value of intestinal ultrasound (US) compared to computerized tomography (CT) in differentiating uncomplicated and complicated acute colonic diverticulitis (ACD). MATERIALS AND METHODS During a period of 14 months patients referred to the department of Radiology with clinical suspicion of ACD underwent an US examination. All confirmed US ACD diagnosis were included and subsequently underwent an emergency abdominal CT, used as gold standard. The WSES (World Society for Emergent Surgery) classification of diverticulitis was used. Diverticulitis was prospectively classified as either uncomplicated or complicated. Sensitivity, specificity, positive predictive value, and negative predictive values of US were evaluated. Before CT scan, the radiologist indicated whether they would have required or not a complementary CT scan, based on US findings. RESULTS Of the 240 patients included in our study, 71 (29.6%) were Stage 0, 127 (53%) Stage 1A, and 42 (17.5%) were moderate-severe ACD (stages 1B, 2A, 2B, 3 and 4). The sensitivity of US for diagnosing complicated ACD was 84% and specificity of 95.8%. Most patients (24 of 27) misclassified by US as uncomplicated diverticulitis were classified on CT as stage 1A. From the 148 cases in which the radiologist considered CT unnecessary, only 3 of these revealed signs of complicated ACD on CT; none of them required emergency surgery. CONCLUSION US is an effective technique to differentiate complicated from uncomplicated ACD. Our results suggest that US, may be a valuable alternative to CT for the initial radiologic evaluation in patients with clinical suspicion of ACD.
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Affiliation(s)
- Tomás Ripollés
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain.
| | | | - María J Martínez-Pérez
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain
| | - Andrea Manrique
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain
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16
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De Vincentis A, Santonico M, Del Chierico F, Altomare A, Marigliano B, Laudisio A, Reddel S, Grasso S, Zompanti A, Pennazza G, Putignani L, Guarino MPL, Cicala M, Antonelli Incalzi R. Gut Microbiota and Related Electronic Multisensorial System Changes in Subjects With Symptomatic Uncomplicated Diverticular Disease Undergoing Rifaximin Therapy. Front Med (Lausanne) 2021; 8:655474. [PMID: 34350192 PMCID: PMC8326398 DOI: 10.3389/fmed.2021.655474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/11/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Intestinal dysbiosis might play a pathogenetic role in subjects with symptomatic uncomplicated diverticular disease (SUDD), but the effect of rifaximin therapy has been scantly explored with regard to gut microbiota variations in patients with SUDD. Aims: To verify to which extent rifaximin treatment affects the gut microbiota and whether an electronic multisensorial assessment of stools and breath has the potential for detecting these changes. Methods: Breath and stool samples were collected from consecutive patients with SUDD before and after a 7 days' therapy with rifaximin. Stool microbiota was assessed, and the electronic multisensorial assessment was carried out by means of the BIONOTE electronic (e-)tongue in stools and (e-)nose in breath. Results: Forty-three subjects (female 60%, median age 66 years) were included, and 20 (47%) reported clinical improvement after rifaximin therapy. Alpha and beta diversity of stool microbiota did not significantly change after treatment, while a significant variation of selected taxa was shown (i.e., Citrobacter, Coprococcus, Anaerotruncus, Blautia, Eggerthella lenta, Dehalobacterium, SMB53, and Haemophilus parainfluenzae). Overall, the electronic multisensorial system suboptimally mirrored microbiota changes, but it was able to efficiently predict patients' clinical improvement after rifaximin with accuracies ranging from 0.81 to 0.98. Conclusions: In patients with SUDD, rifaximin administration is associated with significant variation of selected taxa. While inaccurate in predicting gut microbiota change, an electronic multisensorial system, made up of e-tongue and e-nose, was able to predict clinical improvement, thus potentially qualifying as an easy and cheap tool to forecast subjects taking most likely benefit from rifaximin therapy.
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Affiliation(s)
| | - Marco Santonico
- Unit of Electronics for Sensor Systems, Department of Science and Technology for Humans and the Environment, University Campus Bio-Medico di Roma, Rome, Italy
| | - Federica Del Chierico
- Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Annamaria Altomare
- Unit of Gastroenterology, University Campus Bio Medico of Rome, Rome, Italy
| | | | - Alice Laudisio
- Unit of Geriatrics, University Campus Bio Medico of Rome, Rome, Italy
| | - Sofia Reddel
- Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Simone Grasso
- Unit of Electronics for Sensor Systems, Department of Science and Technology for Humans and the Environment, University Campus Bio-Medico di Roma, Rome, Italy
| | - Alessandro Zompanti
- Unit of Electronics for Sensor Systems, Department of Engineering, University Campus Bio-Medico di Roma, Rome, Italy
| | - Giorgio Pennazza
- Unit of Electronics for Sensor Systems, Department of Engineering, University Campus Bio-Medico di Roma, Rome, Italy
| | - Lorenza Putignani
- Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Diagnostic and Laboratory Medicine, Unit of Microbiology and Diagnostic Immunology, Unit of Parasitology and Multimodal Laboratory Medicine Research Area, Unit of Human Microbiome, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | | | - Michele Cicala
- Unit of Gastroenterology, University Campus Bio Medico of Rome, Rome, Italy
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17
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Gavriilidis P, Askari A, Gavriilidis E, de’Angelis N, Di Saverio S, Wheeler J, Davies RJ. Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. Ann R Coll Surg Engl 2021; 103:471-477. [PMID: 33851878 PMCID: PMC9774019 DOI: 10.1308/rcsann.2021.0013] [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: 11/22/2022] Open
Abstract
INTRODUCTION Diverticular disease is one of the most frequent reasons for attending emergency departments and surgical causes of hospital admission. In the past decade, many surgical and gastroenterological societies have published guidelines for the management of diverticular disease. The aim of the present study was to appraise the methodological quality of these guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. METHODS PubMed, Embase, Cochrane Library and Google Scholar databases were searched systematically. The methodological quality of the guidelines was appraised independently by five appraisers using the AGREE II instrument. FINDINGS A systematic search of the literature identified 12 guidelines. The median overall score of all guidelines was 68%. Across all guidelines, the highest score of 85% was demonstrated in the domain 'Scope and purpose'. The domains 'Clarity and presentation' and 'Editorial independence' both scored a median of 72%. The lowest scores were demonstrated in the domains 'Stakeholder involvement' and 'Applicability' at 46% and 40%, respectively. Overall, the National Institute for Health and Care Excellence (NICE) guidelines performed consistently well, scoring 100% in five of six domains; NICE was one of the few guidelines that specifically reported stakeholder involvement, scoring 97%. Generally, the domain of 'Stakeholder involvement' ranked poorly with seven of twelve guidelines scoring below 50%, with the worst score in this domain demonstrated by Danish guidelines at 25%. CONCLUSION Six of twelve guidelines (NICE, American Society of Colon & Rectal Surgeons (ASCRS), European Society of Coloproctology (ESCP), American Gastroenterological Association, German Society of Gastroenterology/German Society for General and Visceral Surgery (German), Netherlands Society of Surgery) scored above 70%. Only three, NICE, ASCRS and ESCP, scored above 75% and were voted unanimously by the appraisers for use as they are. Therefore, use of AGREE II may help improve the methodological quality of guidelines and their future updates.
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Affiliation(s)
- P Gavriilidis
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, UK
| | - A Askari
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - E Gavriilidis
- University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | - J Wheeler
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - RJ Davies
- Cambridge University Hospitals NHS Foundation Trust, UK
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18
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Leaning M, McSweeney W, Dastouri D. Will a flexi-sig' do? A retrospective review of colonoscopies indicated by diverticulitis alone. Surg Endosc 2021; 36:2949-2953. [PMID: 34110497 DOI: 10.1007/s00464-021-08588-7] [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: 01/12/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The incidence of colonic diverticulitis is increasing. In Australia the majority of diverticulitis occurs in the left colon and patients typically undergo colonoscopy following an attack. At present debate exists regarding the utility of this costly procedure and a flexible sigmoidoscopy has been proposed as a cheaper, less invasive alternative. This paper seeks to examine whether significant pathology is being detected in the right and transverse colon to warrant colonoscopy, as opposed to a flexible sigmoidoscopy. METHODS A retrospective review of colonoscopies performed between August 2016 and August 2018, indicated by diverticulitis alone, performed in a single Australian metropolitan hospital. RESULTS 189 patient colonoscopies were reviewed in combination with the pathology forms. Only 1 primary colonic malignancy was detected, found in the left colon. 110 traditional adenomas and 35 sessile serrated adenomas were detected. 41.8% of patients had a polyp detected with an average of 1.9 polyps per patient. 38.6% of polyps were resected from the left colon while 61.4% were removed from the right and transverse colon. In total 30 polyps > 10 mm or with high-risk histological features were resected, 18 (60%) from the left colon and 12 (40%) from the right and transverse. 20 patients (10.6%) met the criteria for high-risk adenomas and 50% of those had > 40% of their polyps in the right and transverse colon. There was no significant difference in age between patients with polyps and those without. CONCLUSION Despite over half the patients having no polyps and only one left sided malignancy. This study demonstrates that the right and transverse colon is responsible for over 50% of the polyps removed and similar proportion of the advanced polyps. Where endoscopic surveillance after acute colonic diverticulitis is performed, this study supports the use of colonoscopy and cautions against flexible sigmoidoscopy alone.
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Affiliation(s)
- Matthew Leaning
- Dept. General Surgery, Caboolture Hospital, 97/120 McKean Street, Caboolture, QLD, 4510, Australia.
| | - William McSweeney
- Dept. General Surgery, Caboolture Hospital, 97/120 McKean Street, Caboolture, QLD, 4510, Australia
| | - Darius Dastouri
- Dept. General Surgery, Caboolture Hospital, 97/120 McKean Street, Caboolture, QLD, 4510, Australia
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Mikhin IV, Vorontsov OF, Greb K, Nishnevich EV. [Actual issues of diagnosis and treatment of diverticulitis]. Khirurgiia (Mosk) 2021:83-88. [PMID: 33710833 DOI: 10.17116/hirurgia202103183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.
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Affiliation(s)
- I V Mikhin
- Volgograd State Medical University, Volgograd, Russian Federation
| | - O F Vorontsov
- Volgograd State Medical University, Volgograd, Russian Federation.,Sana Klinikum Hof, Hof, Germany
| | - K Greb
- Sana Klinikum Hof, Hof, Germany
| | - E V Nishnevich
- Ural State Medical University, Ekaterinburg, Russian Federation
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20
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Zaborowski AM, Winter DC. Evidence-based treatment strategies for acute diverticulitis. Int J Colorectal Dis 2021; 36:467-475. [PMID: 33156365 DOI: 10.1007/s00384-020-03788-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Alexandra M Zaborowski
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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21
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Saavedra-Perez D, Curbelo-Peña Y, Sampson-Davila J, Albertos S, Serrano A, Ibañez L, Errando X, Perez X. Management of symptomatic uncomplicated diverticular colon disease: A systematic review of diagnosis and treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 44:497-518. [PMID: 33647346 DOI: 10.1016/j.gastrohep.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/28/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
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Affiliation(s)
- David Saavedra-Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España.
| | - Yuhamy Curbelo-Peña
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Jaime Sampson-Davila
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Sonia Albertos
- Servicio de Digestología, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Alejandro Serrano
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Luis Ibañez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Errando
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
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22
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Frieling T. [Diverticula in the gastrointestinal tract]. Internist (Berl) 2021; 62:277-287. [PMID: 33560449 DOI: 10.1007/s00108-021-00942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.
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Affiliation(s)
- Thomas Frieling
- Medizinische Klinik II, Klinik für Innere Medizin mit Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Gastrointestinaler Onkologie, Hämatoonkologie und Palliativmedizin, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Deutschland.
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23
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Duarte-Chavez R, Stoltzfus J, Yellapu V, Martins N, Nanda S, Longo S, Geme B, Schneider Y. Colonic diverticular disease in autosomal dominant polycystic kidney disease: is there really an association? A nationwide analysis. Int J Colorectal Dis 2021; 36:83-91. [PMID: 32875377 DOI: 10.1007/s00384-020-03736-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Colonic diverticulosis, diverticulitis, and diverticular bleeding are reportedly more common in patients with autosomal dominant polycystic kidney disease (ADPKD). Other studies have questioned this association. The objectives of our study are to clarify this association using a larger patient population and to identify risk factors in general to develop diverticular disease. METHODS The Nationwide Inpatient Sample weighted discharges from 2003 to 2011 were used to assess for the prevalence of diverticular disease in the population with ADPKD compared with the general population without ADPKD. A multivariable direct logistic regression model was constructed to determine independent predictors of diverticular disease in the general population. RESULTS The prevalence of diverticulosis, diverticulitis, and diverticular bleeding were considerably increased in patients with ADPKD compared with the general population without ADPKD. The prevalence of colonic surgery was less in ADPKD patients with diverticulitis. In patients with kidney transplant, the prevalence of diverticulitis was increased in the ADPKD group, but colonic surgery was not significantly different between both groups. The prevalence of diverticular bleeding was slightly elevated in patients with ADPKD, but colonic surgery was significantly increased in patients with ADPKD. NSAID use, hypertension, constipation, and ADPKD had increased odds ratios for diverticular disease during multivariate analysis. CONCLUSION There is an increased prevalence of colonic diverticular disease in the population with ADPKD.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
| | - Jill Stoltzfus
- Department of Research, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Vikas Yellapu
- Department of Research, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Noel Martins
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Sudip Nanda
- Department of Internal Medicine, Division of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Berhanu Geme
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
| | - Yecheskel Schneider
- Department of Internal Medicine, Division of Gastroenterology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA
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24
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Lauscher JC, Lock JF, Aschenbrenner K, Strobel RM, Leonhardt M, Stroux A, Weixler B, Germer CT, Kreis ME. Validation of the German Classification of Diverticular Disease (VADIS)-a prospective bicentric observational study. Int J Colorectal Dis 2021; 36:103-115. [PMID: 32886196 PMCID: PMC7782437 DOI: 10.1007/s00384-020-03721-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The German Classification of Diverticular Disease was introduced a few years ago. The aim of this study was to determine whether Classification of Diverticular Disease enables an exact stratification of different types of diverticular disease in terms of course and treatment. METHODS This was a prospective, bicentric observational trial. Patients aged ≥ 18 years with diverticular disease were prospectively included. The primary endpoint was the rate of recurrence within 2 year follow-up. Secondary outcome measures were Gastrointestinal Quality of Life Index, Quality of life measured by SF-36, frequency of gastrointestinal complaints, and postoperative complications. RESULTS A total of 172 patients were included. After conservative management, 40% of patients required surgery for recurrence in type 1b vs. 80% in type 2a/b (p = 0.04). Sixty percent of patients with type 2a (micro-abscess) were in need of surgery for recurrence vs. 100% of patients with type 2b (macro-abscess) (p = 0.11). Patients with type 2a reached 123 ± 15 points in the Gastrointestinal Quality of Life Index compared with 111 ± 14 in type 2b (p = 0.05) and higher scores in the "Mental Component Summary" scale of SF-36 (52 ± 10 vs. 43 ± 13; p = 0.04). Patients with recurrent diverticulitis without complications (type 3b) had less often painful constipation (30% vs. 73%; p = 0.006) when they were operated compared with conservative treatment. CONCLUSION Differentiation into type 2a and 2b based on abscess size seems reasonable as patients with type 2b required surgery while patients with type 2a may be treated conservatively. Sigmoid colectomy in patients with type 3b seems to have gastrointestinal complaints during long-term follow-up. TRIAL REGISTRATION https://www.drks.de ID: DRKS00005576.
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Affiliation(s)
- Johannes C. Lauscher
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Johan F. Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Katja Aschenbrenner
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Rahel M. Strobel
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Marja Leonhardt
- Innlandet Hospital Trust, Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Brumunddal, Norway
| | - Andrea Stroux
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany ,Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Benjamin Weixler
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Martin E. Kreis
- Department of General, Visceral and Vascular Surgery, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
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25
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Pochhammer J, Kramer A, Orth M, Schäffer M, Beckmann JH. Treatment with Ceftriaxone in Complicated Diverticulitis Increases the Incidence of Intra-Abdominal Enterococcus faecium Detection. Surg Infect (Larchmt) 2020; 22:543-550. [PMID: 33112712 DOI: 10.1089/sur.2020.057] [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: 11/13/2022] Open
Abstract
Background: Complicated diverticulitis of the sigmoid colon typically is treated by resection after initial antibiotic treatment. Third-generation cephalosporins are the drugs of choice but are not effective against enterococci and can induce colonic colonization by Enterococcus faecium within hours. Infections caused by enterococci, especially E. faecium, are difficult to treat but should be considered in the strategic treatment planning of hospital-acquired peritonitis (e.g., anastomotic leakage), especially in immunocompromised patients. Methods: To determine whether the duration of pre-operative ceftriaxone treatment in complicated diverticulitis increases the incidence of intra-abdominal E. faecium detection, we analyzed all patients operated on for diverticulitis of the sigmoid colon in our department between 2008 and 2016. Results: Analyzing 516 resections performed for complicated diverticulitis, we found that E. faecium generally was detected intra-abdominally more often in the group that underwent longer pre-operative ceftriaxone treatment (≥ 4 days). During primary resection, E. faecium was detected in 2.7%, 11.1%, and 37.0% cases in the group undergoing immediate operation, 1-3 days of antibiotic treatment, and ≥4 days of antibiotic treatment, respectively. Enterococcus faecium was detected in 0, 25.0%, and 70.6% of surgical revisions and 28.6%, 14.3%, and 56.0%, respectively, of incisional surgical site infections with identified pathogens. A multivariable analysis discovered anastomotic leakage and antibiotic treatment lasting ≥4 days to be independent risk factors for intra-abdominal isolation of E. faecium. Conclusion: A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal E. faecium. Our data further suggested that empiric coverage of E. faecium in the treatment of hospital-acquired peritonitis could be beneficial after a long duration of ceftriaxone treatment.
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Affiliation(s)
- Julius Pochhammer
- Department of Visceral and Thoracic Surgery, University Hospital Schleswig-Holstein, Christian-Albrechts-University Kiel, Kiel, Germany.,Marienhospital Stuttgart, Department of Visceral, General, and Thoracic Surgery, Stuttgart, Germany
| | - Axel Kramer
- Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Orth
- Marienhospital Stuttgart, Institute for Laboratory Medicine, Stuttgart, Germany and Heidelberg University, Medical Faculty of Mannheim, Mannheim, Germany
| | - Michael Schäffer
- Marienhospital Stuttgart, Department of Visceral, General, and Thoracic Surgery, Stuttgart, Germany
| | - Jan Henrik Beckmann
- Department of Visceral and Thoracic Surgery, University Hospital Schleswig-Holstein, Christian-Albrechts-University Kiel, Kiel, Germany
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26
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Short- and long-term outcomes for primary anastomosis versus Hartmann's procedure in Hinchey III and IV diverticulitis: a multivariate logistic regression analysis of risk factors. Langenbecks Arch Surg 2020; 406:121-129. [PMID: 33083847 PMCID: PMC7870590 DOI: 10.1007/s00423-020-02015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/16/2020] [Indexed: 11/13/2022]
Abstract
Purpose The management of perforated diverticulitis with generalized peritonitis is still controversial and no preferred standardized therapeutic approach has been determined. We compared surgical outcomes between Hartmann’s procedure (HP) and primary anastomosis (PA) in patients with Hinchey III and IV perforated diverticulitis. Methods Multicenter retrospective analysis of 131 consecutive patients with Hinchey III and IV diverticulitis operated either with HP or PA from 2015 to 2018. Postoperative morbidity was compared after adjustment for known risk factors in a multivariate logistic regression. Results Sixty-six patients underwent HP, while PA was carried out in 65 patients, 35.8% of those were defunctioned. HP was more performed in older patients (74.6 vs. 61.2 years, p < .001), with Hinchey IV diverticulitis (37% vs. 7%, p < .001) and in patients with worse prognostic scores (P-POSSUM Physiology Score, p < .001, Charlson Comorbidity Index p < .001). Major morbidity and mortality were higher in HP compared to PA (30.3% vs. 9.2%, p = .002 and 10.6% vs. 0%, p = .007, respectively) with lower stoma reversal rate (43.9% vs. 86.9%, p < .001). In a multivariate logistic regression, PA was independently associated with lower postoperative morbidity and mortality (OR 0.24, 95% CI 0.06–0.96, p = .044). Conclusions In comparison to PA, HP is associated with a higher morbidity, higher mortality, and a lower stoma reversal rate. Although a higher prevalence of risk factors in HP patients may explain these outcomes, a significant increase in morbidity and mortality persisted in a multivariate logistic regression analysis that was stratified for the identified risk factors.
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27
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Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020; 22 Suppl 2:5-28. [PMID: 32638537 DOI: 10.1111/codi.15140] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
AIM The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.
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Affiliation(s)
- J K Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - G A Binda
- Colorectal Surgery, BioMedical Institute, Genova, Italy
| | - G Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Biondo
- Department of General and Digestive Surgery - Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Chabok
- Colorectal Unit, Department of Surgery, Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S T van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Johanssen
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - W Kruis
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - D Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Post
- Mannheim Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - F Ris
- Division of Visceral Surgery, Geneva University hospitals and Medical School, Geneva, Switzerland
| | - T A Rockall
- Minimal Access Therapy Training Unit (mattu), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - A Samuelsson
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.,Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University Hospital of Varese, University of Insubria, Varese, Italy
| | - D Tartaglia
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - A Thorisson
- Department of Radiology, Västmanland's Hospital Västerås, Västerås, Sweden.,Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, Västerås, Sweden
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
| | - W Bemelman
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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El Zanati H, Chen A, Attiya A, Leung E. Is routine colonoscopy necessary for patients who have an unequivocal computerised tomography diagnosis of acute diverticulitis? Scott Med J 2020; 66:11-15. [PMID: 32781909 DOI: 10.1177/0036933020949228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To assess the incidence of underlying colorectal malignancy in patients admitted as an emergency with a CT diagnosis of acute diverticulitis and determine the need for routine follow up colonoscopy. METHODS A retrospective study was performed on all patients who had been admitted to our surgical unit with CT diagnosed diverticulitis from September 2016 to September 2018 (n = 125). RESULTS 11 patients (8.8%) required emergency resection with no underlying malignancy found. 76 patients (61%) had a follow up colonoscopy after being discharged. 4 patients were found to have an underlying colorectal malignancy, one of them suspected on CT and another an incidentally detected caecal polyp cancer. Therefore 3/87(3.4%) had an unexpected cancer diagnosis and all those in the diseased segment were within complicated diverticulitis. CONCLUSION Nowadays, multi-slice CT scanners are so good at giving an accurate assessment of colonic pathology. In our study, 96.6% of the patients with a CT diagnosis of acute diverticulitis had no underlying malignancy in the diseased segment with all the cancers within complicated diverticulitis. With such a low yield of underlying malignancy in uncomplicated diverticulitis, we question the need for routine follow up colonoscopy when there is no CT suspicion of malignancy in these patients.
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Affiliation(s)
- Hisham El Zanati
- Specialty doctor in Surgery, General Surgery Department, University Hospital Crosshouse, UK
| | - Adriel Chen
- Foundation year 1 doctor, General Surgery Department, Hairmyres University Hospital, UK
| | - Abdulaziz Attiya
- Specialty doctor in surgery, General Surgery Department, Hairmyres University Hospital, UK
| | - Edward Leung
- Consultant general surgeon, General Surgery Department, University Hospital Crosshouse, UK
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A Hospital Protocol for Decision Making in Emergency Admission for Acute Diverticulitis: Initial Results from Small Cohort Series. ACTA ACUST UNITED AC 2020; 56:medicina56080371. [PMID: 32722066 PMCID: PMC7466311 DOI: 10.3390/medicina56080371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Background and objectives: We present initial results from a small cohort series for a hospital protocol related to the emergency hospitalization decision-making process for acute diverticulitis. We performed a retrospective analysis of 53 patients with acute diverticulitis admitted to the Department of Emergency and Trauma Surgery of the "Azienda Ospedaliero Universiaria-Ospedali Riuniti" in Ancona and to the Department of General and Emergency Surgery of the "Azienda Ospedaliera-Universitaria" in Perugia. Materials and Methods: All patients were evaluated according to hemodynamic status: stable or unstable. Secondly, it was distinguished whether patients were suffering from complicated or uncomplicated forms of diverticulitis. Finally, each patient was assigned to a risk class. In this way, we established a therapeutic/diagnostic process for each group of patients. Results: Non-operative treatment (NonOP) was performed in 16 patients, and it was successful in 69% of cases. This protocol primarily considers the patient's clinical condition and the severity of the disease. It is based on a multidisciplinary approach, in order to implement the most suitable treatment for each patient. In stable patients with uncomplicated diverticulitis or complicated Hinchey grade 1 or 2 diverticulitis, the management is conservative. In all grade 3 and grade 4 forms, patients should undergo urgent surgery. Conclusions: This protocol, which is based on both anatomical damage and the severity of clinical conditions, aims to standardize the choice of the best diagnostic and therapeutic strategy for the patient in order to reduce mortality and morbidity related to this pathology.
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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31
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Sohn M, Agha A, Iesalnieks I, Bremer S, Trum S, Di Cerbo F, Nerlich A, Lotz N, Klieser E, Hochrein A, Schredl P, Kalcheva D, Emmanuel K, Presl J. PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease: the PREDIC-DIV study protocol of a prospective multicentric transnational observational study. BMJ Open 2020; 10:e034385. [PMID: 32209628 PMCID: PMC7202696 DOI: 10.1136/bmjopen-2019-034385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Diverticulitis is among the most common abdominal disorders. The best treatment strategy for this complicated disease as well as for recurrent stages is still under debate. Moreover, little knowledge exists regarding the effect of different therapeutic strategies on the health-related quality of life (HrQoL). Therefore, the PREDIC-DIV (PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease) study aims to assess predictors of a change in HrQoL in patients after elective sigmoidectomy for diverticular disease. METHODS AND ANALYSIS A prospective multicentre transnational observational study was started in November 2017. Patients undergoing elective sigmoid resection for diverticular disease were included. Primary outcome includes HrQoL 6 months postoperatively, staged by the Gastrointestinal Quality of Life Index (GIQLI). Secondary outcomes include HrQoL 6 months after sigmoidectomy, assessed using the Short Form 36 Questionnaire and a custom-made Visual Analogue Scale-based inventory; HrQoL after 12 and 24 months; postoperative morbidity; mortality; influence of surgical technique (conventional laparoscopic multiport operation vs robotic approach); histological grading of inflammation and morphological characteristics of the bowel wall in the resected specimen; postoperative functional changes (faecal incontinence, faecal urge, completeness of emptying, urinary incontinence, sexual function); disease-specific healthcare costs; and changes in economic productivity, measured by the iMTA Productivity Cost Questionnaire. The total follow-up will be 2 years. ETHICS AND DISSEMINATION The protocol was approved by the medical ethical committee of the Bavarian Medical Council (report identification number: 2017-177). The study was conducted in accordance with the Declaration of Helsinki. The findings of this study will be submitted to a peer-reviewed journal (BMJ Open, Annals of Surgery, British Journal of Surgery, Diseases of the Colon and the Rectum). Abstracts will be submitted to relevant national and international conferences. TRIAL REGISTRATION NUMBER The study is registered with the ClinicalTrials.gov register as NCT03527706; Pre-results.
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Affiliation(s)
| | - Ayman Agha
- München Klinik Bogenhausen, Munich, Bayern, Germany
| | | | | | | | | | | | - Natalie Lotz
- München Klinik Bogenhausen, Munich, Bayern, Germany
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32
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Ryan OK, Ryan ÉJ, Creavin B, Boland MR, Kelly ME, Winter DC. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann’s procedure for the management of acute perforated diverticulitis with generalised peritonitis. Tech Coloproctol 2020; 24:527-543. [DOI: 10.1007/s10151-020-02172-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/07/2020] [Indexed: 12/29/2022]
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van Dijk ST, Chabok A, Dijkgraaf MG, Boermeester MA, Smedh K. Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis. Br J Surg 2020; 107:1062-1069. [PMID: 32073652 PMCID: PMC7318319 DOI: 10.1002/bjs.11465] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/02/2019] [Accepted: 11/15/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND Two RCTs (AVOD and DIABOLO) demonstrated no difference in recovery or adverse outcomes when antibiotics for acute uncomplicated diverticulitis were omitted. Both trials showed non-significantly higher rates of complicated diverticulitis and surgery in the non-antibiotic groups. This meta-analysis of individual-patient data aimed to explore adverse outcomes and identify patients at risk who may benefit from antibiotic treatment. METHODS Individual-patient data from those with uncomplicated diverticulitis from two RCTs were pooled. Risk factors for adverse outcomes and the effect of observational management were assessed using logistic regression analyses. P < 0·025 was considered statistically significant owing to multiple testing adjustment. RESULTS In total, 545 patients in the observational group and 564 in the antibiotics group were included. No statistical differences were found in 1-year follow-up rates of ongoing diverticulitis (7·2 versus 5·0 per cent in observation versus antibiotics groups respectively; P = 0·062), recurrent diverticulitis (8·6 versus 9·6 per cent; P = 0·610), complicated diverticulitis (4·0 versus 2·1 per cent; P = 0·079) and sigmoid resection (5·0 versus 2·5 per cent; P = 0·214). An initial pain score greater than 7, white blood cell count exceeding 13·5 × 109 /l and previous diverticulitis at presentation were risk factors for adverse outcomes. Antibiotic treatment did not prevent adverse outcomes in patients at high risk of adverse events. CONCLUSION Observational management of acute uncomplicated diverticulitis is safe. Some statistical uncertainty remains, depending on the thresholds of clinical relevance, owing to small differences, but no subgroup that would benefit from antibiotic treatment was apparent.
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Affiliation(s)
- S T van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | - A Chabok
- Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital, Västerås, Sweden
| | - M G Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | - K Smedh
- Department of Surgery, and Centre for Clinical Research Uppsala University, Västmanlands Hospital, Västerås, Sweden
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Common variation in FAM155A is associated with diverticulitis but not diverticulosis. Sci Rep 2020; 10:1658. [PMID: 32015353 PMCID: PMC6997170 DOI: 10.1038/s41598-020-58437-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 01/14/2020] [Indexed: 11/25/2022] Open
Abstract
Colonic diverticulosis is a very common condition. Many patients develop diverticulitis or other complications of diverticular disease. Recent genome-wide association studies (GWAS) consistently identified three major genetic susceptibility factors for both conditions, but did not discriminate diverticulititis and diverticulosis in particular due the limitations of registry-based approaches. Here, we aimed to confirm the role of the identified variants for diverticulosis and diverticulitis, respectively, within a well-phenotyped cohort of patients who underwent colonoscopy. Risk variants rs4662344 in Rho GTPase-activating protein 15 (ARHGAP15), rs7609897 in collagen-like tail subunit of asymmetric acetylcholinesterase (COLQ) and rs67153654 in family with sequence similarity 155 A (FAM155A) were genotyped in 1,332 patients. Diverticulosis was assessed by colonoscopy, and diverticulitis by imaging, clinical symptoms and inflammatory markers. Risk of diverticulosis and diverticulitis was analyzed in regression models adjusted for cofactors. Overall, the variant in FAM155A was associated with diverticulitis, but not diverticulosis, when controlling for age, BMI, alcohol consumption, and smoking status (ORadjusted 0.49 [95% CI 0.27–0.89], p = 0.002). Our results contribute to the assessment specific genetic variants identified in GWAS in the predisposition to the development of diverticulitis in patients with diverticulosis.
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Rottier SJ, van Dijk ST, van Geloven AAW, Schreurs WH, Draaisma WA, van Enst WA, Puylaert JBCM, de Boer MGJ, Klarenbeek BR, Otte JA, Felt RJF, Boermeester MA. Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis. Br J Surg 2020; 106:988-997. [PMID: 31260589 PMCID: PMC6618242 DOI: 10.1002/bjs.11191] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/12/2019] [Accepted: 03/05/2019] [Indexed: 02/06/2023]
Abstract
Background Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis. Methods PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls. Results Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent. Conclusion Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.
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Affiliation(s)
- S J Rottier
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands.,Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands.,Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands
| | - S T van Dijk
- Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - W H Schreurs
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - W A Draaisma
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - W A van Enst
- Knowledge Institute of Medical Specialists, Utrecht, the Netherlands
| | | | - M G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, the Netherlands
| | - B R Klarenbeek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J A Otte
- Department of Internal Medicine, ZorgSaam Hospital, Terneuzen, the Netherlands
| | - R J F Felt
- Departments of Gastroenterology, Amsterdam UMC, Amsterdam, the Netherlands
| | - M A Boermeester
- Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
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Disease phenotype rather than treatment strategy impacts the long-term quality of life in patients with diverticular disease. Int J Colorectal Dis 2019; 34:1749-1756. [PMID: 31492987 DOI: 10.1007/s00384-019-03385-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To identify the impact of the severity of diverticular disease on long-term quality of life. METHODS Consecutive patients, hospitalized between October 2009 and November 2015 due to uncomplicated (UD) and complicated diverticulitis (CD) of the left colon, were analyzed. Patients undergoing emergent surgery for perforated disease were excluded. Primary endpoint was health-related quality of life (HrQol), measured by the Short Form 36 questionnaire (SF-36). Physical (PCS) and mental (MCS) compository scores were calculated from SF-36 subscales. To overcome bias, one-to-one propensity score matching and multivariable logistic regression analysis were performed. RESULTS Two hundred eighty of the overall 392 patients (Male 138, Female 142; mean age 60.5 years, range 27-91) answered the SF-36 questionnaire. The median follow-up period was 37.8 months (range 15-85). After propensity score matching, each group consisted of 51 patients. Results of the SF-36 questionnaires showed a statistically significant difference, favoring patients with CD in 5 of 8 domains. Also, PCS (56.3 vs. 52.9, p = 0.13) and MCS (53.3 vs. 46.7, p = 0.005) were higher in patients treated for CD. By a multivariate analysis, complicated disease was independently associated with a better scoring on 6 out of 8 SF-36 subscales and on MCS. Treatment strategy (surgery or conservative) did not have any impact on SF-36 subscales, MCS, or PCS on multivariate analysis. CONCLUSION In contrast to complicated disease, the uncomplicated diverticular disease is associated with an impaired long-term quality of life especially in domains composing mental health scores independently of chosen treatment strategy. STUDY REGISTRATION The study is registered with the Research Registry at June 19, 2019. Research registry UIN: researchregistry4959 .
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Abstract
CLINICAL/METHODICAL ISSUE Diagnostic imaging plays a crucial role in the assessment and stratification of pathologic conditions causing acute abdomen. This report provides information on etiology, clinical manifestations and therapeutic options for six common diseases resulting in acute abdomen-appendicitis, cholecystitis, bowel obstruction, diverticulitis, acute pancreatitis, and viscus perforation. PERFORMANCE Besides initial ultrasound, CT scans often represent the imaging gold standard for the diagnostic evaluation of acute abdomen. PRACTICAL RECOMMENDATIONS Depending on the underlying pathologic condition, sonography or CT is suitable for the stratification of the gastrointestinal disease causing acute abdomen.
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Affiliation(s)
- V Schwarze
- Klinik und Poliklinik für Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Grosshadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - C Marschner
- Klinik und Poliklinik für Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Grosshadern, Marchioninistr. 15, 81377, München, Deutschland
| | - C Schulz
- Medizinische Klinik und Poliklinik II, Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - F Streitparth
- Klinik und Poliklinik für Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Grosshadern, Marchioninistr. 15, 81377, München, Deutschland
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Tachezy M, Izbicki JR. [Evidence for standard surgical procedures: appendicitis, diverticulitis and cholecystitis]. Chirurg 2019; 90:351-356. [PMID: 30635701 DOI: 10.1007/s00104-018-0779-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute appendicitis, cholecystitis and sigmoid diverticulitis are the most common inflammatory visceral surgical emergencies. According to the principles of evidence-based medicine, treatment methods and surgical indications should be constantly questioned and validated by high-quality clinical studies. OBJECTIVE To identify and classify the current evidence on surgical treatment of acute appendicitis, cholecystitis and sigmoid diverticulitis. MATERIAL AND METHODS Targeted literature search in Medline, the Cochrane Library and study registers (clinicaltrials.gov). RESULTS AND CONCLUSION The indications for surgery are changing due to increasing numbers of high-quality clinical studies. Conservative treatment seems to be feasible in the early stages. In contrast, many surgical steps have not yet been sufficiently validated. Furthermore, there is a great need for high-quality, prospective randomized clinical trials, so that promotion of studies and the study culture in surgery should continue to be of greatest interest.
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Affiliation(s)
- M Tachezy
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - J R Izbicki
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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Wada M, Nishizawa T, Kato M, Hirai Y, Kinoshita S, Mori H, Nakazato Y, Fujimoto A, Kikuchi M, Uraoka T, Kanai T. Colonic diverticular bleeding and predictors of the length of hospitalization: An observational study. J Gastroenterol Hepatol 2019; 34:1351-1356. [PMID: 30636058 DOI: 10.1111/jgh.14603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM A significant percentage of patients with colonic diverticular bleeding (CDB) experience bleeding that is severe enough to necessitate prolonged hospitalization. Prolonged hospitalization causes deterioration in patients' quality of life, as well as difficulties with cost-effective utilization of medical resources, and is a financial burden to the society. Therefore, we investigated the factors associated with the length of hospitalization for the optimal management of patients hospitalized with CDB. METHODS This study included patients who were hospitalized for the treatment of CDB and underwent colonoscopy between July 2008 and February 2016. Logistic regression analysis was performed to investigate the association between the length of hospitalization and the patients' baseline characteristics, in-hospital procedures performed, and the clinical outcomes. RESULTS The study included 223 patients. Diabetes mellitus (odds ratio [OR] 3.4, P = 0.014) and blood transfusion (OR 3.1, P = 0.0006) were identified as risk factors for prolonged hospitalization (≥ 8 days). Urgent colonoscopy (OR 0.41, P = 0.0072) predicted a shorter length of hospitalization (≤ 7 days). The study also indicated that endoscopic treatment showed a stronger association with urgent colonoscopy (OR 7.8, P < 0.0001) than with elective colonoscopy and that urgent colonoscopy was not associated with an increased rate of adverse events or re-bleeding. CONCLUSIONS Compared with elective colonoscopy, urgent colonoscopy shortens the length of hospitalization in patients with CDB. Moreover, it is not associated with an increased rate of adverse events. Urgent colonoscopy may be impracticable in a few cases; however, if possible, aggressive urgent colonoscopy should be considered for the efficient management of the patient's hospital stay.
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Affiliation(s)
- Michiko Wada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology and Hepatology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshihiro Nakazato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Ai Fujimoto
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Broad JB, Wu Z, Ng J, Arroll B, Connolly MJ, Jaung R, Oliver F, Bissett IP. Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care? PLoS One 2019; 14:e0219818. [PMID: 31314796 PMCID: PMC6636816 DOI: 10.1371/journal.pone.0219818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed. AIM To estimate how often DDI is managed in primary care, using antibiotics dispensing data. DESIGN AND SETTING Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics. METHOD Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use. RESULTS From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation. CONCLUSION DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.
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Affiliation(s)
- Joanna B. Broad
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Zhenqiang Wu
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Jerome Ng
- Institute for Innovation and Improvement, Waitematā District Health Board, Auckland, New Zealand
| | - Bruce Arroll
- Department of General Practice and Primary Healthcare, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Martin J. Connolly
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
- Waitematā District Health Board, Auckland, New Zealand
| | - Rebekah Jaung
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Frances Oliver
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Cremon C, Carabotti M, Cuomo R, Pace F, Andreozzi P, Barbaro MR, Annibale B, Barbara G. Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry. United European Gastroenterol J 2019; 7:815-824. [PMID: 31316786 PMCID: PMC6620876 DOI: 10.1177/2050640619845990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although diverticular disease is a common condition, its effective treatment is challenging in clinical practice. OBJECTIVE The objective of this article is to assess pharmacological management in different clinical settings of diverticular disease and factors associated with treatment using the Italian registry Registro Malattia Diverticolare (REMAD). METHODS At study enrolment, patients were categorised into subgroups: diverticulosis, symptomatic uncomplicated diverticular disease and previous diverticulitis. We registered demographic, clinical and lifestyle factors, quality of life and the use of treatments for diverticular disease in the last year. Logistic regression analysis assessed the association between clinical factors and treatment consumption. RESULTS A total of 500 of the 1206 individuals included had had at least one treatment for diverticular disease in the last year: 23.6% (166/702) of patients with diverticulosis, 55.9% (165/295) of patients with symptomatic diverticular disease, and 80.9% (169/209) of patients with previous diverticulitis (p < 0.001). In multivariate analysis, the following factors were significantly associated with treatment use: female gender, family history of colonic diverticula, organic digestive comorbidity and impaired physical quality of life components. CONCLUSION Individuals with diverticular disease take medications based on the different clinical settings of disease. We identified different features associated with treatment use in the distinct clinical entities of diverticular disease.ClinicalTrial.gov Identifier: NCT03325829.
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Affiliation(s)
- Cesare Cremon
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Rosario Cuomo
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Fabio Pace
- Unit of Gastroenterology, “Bolognini” Hospital, Bergamo, Italy
| | - Paolo Andreozzi
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Maria Raffaella Barbaro
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
- Giovanni Barbara, St Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, Building #5, Via Massarenti, 9, I-40138 Bologna, Italy.
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Carabotti M, Annibale B. Mesalamine (5-ASA) for the prevention of recurrent diverticulitis (Review). Tech Coloproctol 2019; 23:597-599. [PMID: 31346815 DOI: 10.1007/s10151-019-02037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Affiliation(s)
- M Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
| | - B Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy.
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Kawada K, Kobayashi T, Watanabe T, Inamoto S, Goto T, Mizuno R, Sakai Y. Combined laparoscopic and cystoscopic surgery for colovesical fistula due to colonic diverticulitis. Tech Coloproctol 2019; 23:503-504. [PMID: 30989417 DOI: 10.1007/s10151-019-01981-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Affiliation(s)
- K Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - T Kobayashi
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - T Watanabe
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - S Inamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - T Goto
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - R Mizuno
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Y Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Strate LL, Morris AM, Hinchey EJ, Lough JO, Goresky CA. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology 2019; 156:1282-1298.e1. [PMID: 30660732 PMCID: PMC6716971 DOI: 10.1053/j.gastro.2018.12.033] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
Abstract
Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.
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Affiliation(s)
- Lisa L. Strate
- Division of Gastroenterology, University of Washington School of Medicine, Harborview Medical Center, 325 Ninth Ave, Box 359773, Seattle, WA 98104
| | - Arden M. Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford California, 1070 Arastradero Rd, Ste 217, CA 94305
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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Response to Karakonstantis et al. Am J Gastroenterol 2019; 114:692. [PMID: 30908298 DOI: 10.14309/ajg.0000000000000207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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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Ubaldi E, Grattagliano I, Lapi F, Pecchioli S, Cricelli C. Overview on the management of diverticular disease by Italian General Practitioners. Dig Liver Dis 2019; 51:63-67. [PMID: 30143468 DOI: 10.1016/j.dld.2018.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although very common in Western countries, poor epidemiological data on diverticular disease (DD) is available from the family practice. AIMS To evaluate the behavior of Italian General Practitioners (GPs) on approaching DD. METHODS Health Search Database was analyzed retrospectively. RESULTS On a population of 975,523 individuals, 33,597 patients had a registered diagnosis of DD ("lifetime" prevalence = 3.4%, M = 3.2%, F = 3.7%; higher values are found in females over-65 years old; low rates of complications: diverticulitis = 0.3%, bleeding = 0.002%). As risk factors, NSAIDs and ASA were taken by 14.8% and 26.5% respectively, opioids by 7.5%, corticosteroids by 5.2%; as protective factors, 30.4% were under statins and 17.7% under calcium-antagonists. Approximately 13% of patients were referred to specialists. Colonoscopy and abdominal CT were prescribed to 48.5% and to 13% of already diagnosed patients. Among DD sufferers, 27% experienced hospitalization, but only 3.4% of cases were for a DD-linked problem. Treatment included rifaximin (61%), mesalazine (14.7%), probiotics (12.4%), ciprofloxacin (7.6%). CONCLUSION DD has a large impact in general practice with a higher prevalence in the elderly. GPs are required to pay particular attention to risk factors both for disease development and for its complications in order to reduce the costs deriving from diagnostic procedures, referral and hospitalization.
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Affiliation(s)
- Enzo Ubaldi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Francesco Lapi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Serena Pecchioli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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Sohn M, Iesalnieks I, Agha A, Steiner P, Hochrein A, Pratschke J, Ritschl P, Aigner F. Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy". World J Surg 2018. [PMID: 29541823 DOI: 10.1007/s00268-018-4585-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a "Damage Control Strategy" (DCS). MATERIALS AND METHODS Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann's procedure) after 24-48 h. RESULTS Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30-92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3-66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%). CONCLUSION The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.
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Affiliation(s)
- Maximilian Sohn
- Klinik für Allgemein-, Viszeral-, Endokrine- und minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Strasse 77, 81925, Munich, Germany.
| | - I Iesalnieks
- Klinik für Allgemein-, Viszeral-, Endokrine- und minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Strasse 77, 81925, Munich, Germany
| | - A Agha
- Klinik für Allgemein-, Viszeral-, Endokrine- und minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Strasse 77, 81925, Munich, Germany
| | - P Steiner
- Klinik für Allgemein, Viszeral- und Gefäßchirurgie-, Klinikum Harlaching, Städtisches Klinikum München GmbH, Munich, Germany
| | | | - J Pratschke
- Chirurgische Klinik, Charité - Universitätsmedizin Berlin, Campus Charité Mitte|Campus Virchow-Klinikum, Berlin, Germany
| | - P Ritschl
- Chirurgische Klinik, Charité - Universitätsmedizin Berlin, Campus Charité Mitte|Campus Virchow-Klinikum, Berlin, Germany
| | - F Aigner
- Chirurgische Klinik, Charité - Universitätsmedizin Berlin, Campus Charité Mitte|Campus Virchow-Klinikum, Berlin, Germany
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