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Sartelli M, Binda GA, Brandara F, Borasi A, Feroci F, Vadalà S, Labricciosa FM, Birindelli A, Luridiana G, Coccolini F, Di Saverio S, Catena F, Ansaloni L, Campanile FC, Agresta F, Piazza D. IPOD Study: Management of Acute Left Colonic Diverticulitis in Italian Surgical Departments. World J Surg 2017; 41:851-859. [PMID: 27834014 DOI: 10.1007/s00268-016-3800-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In recent years, the emergency management of acute left colonic diverticulitis (ALCD) has evolved dramatically despite lack of strong evidence. As a consequence, management strategies are frequently guided by surgeon's personal preference, rather than by scientific evidence. The primary aim of IPOD study (Italian Prospective Observational Diverticulitis study) is to describe both the diagnostic and treatment profiles of patients with ALCD in the Italian surgical departments. METHODS IPOD study is a prospective observational study performed during a 6-month period (from April 1 2015 to September 1 2015) and including 89 Italian surgical departments. All consecutive patients with suspected clinical diagnosis of ALCD confirmed by imaging and seen by a surgeon were included in the study. The study was promoted by the Italian Society of Hospital Surgeons and the World Society of Emergency Surgery Italian chapter. RESULTS Eleven hundred and twenty-five patients with a median age of 62 years [interquartile range (IQR), 51-74] were enrolled in the IPOD study. One thousand and fifty-four (93.7%) patients were hospitalized with a median duration of hospitalization of 7 days (IQR 5-10). Eight hundred and twenty-eight patients (73.6%) underwent medical treatment alone, 13 patients had percutaneous drainage (1.2%), and the other 284 (25.2%) patients underwent surgery as first treatment. Among 121 patients having diffuse peritonitis, 71 (58.7%) underwent Hartmann's resection. However, the Hartmann's resection was used even in patients with lower stages of ALCD (36/479; 7.5%) where other treatment options could be more adequate. CONCLUSIONS The IPOD study demonstrates that in the Italian surgical departments treatment strategies for ALCD are often guided by the surgeon's personal preference.
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Affiliation(s)
| | | | | | - Andrea Borasi
- Department of General Surgery, Humanitas Gradenigo, Turin, Italy
| | | | | | - Francesco M Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | | | | | | | - Salomone Di Saverio
- General Surgery, Emergency and Trauma Surgery Unit, Maggiore Hospital, Bologna, Italy.
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fabio Cesare Campanile
- Unit of General Surgery, AUSL VT, San Giovanni Decollato-Andosilla Hospital, Civita Castellana, Italy
| | | | - Diego Piazza
- Department of Surgery, Vittorio Emanuele Hospital, Catania, Italy
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Mozer AB, Spaniolas K, Sippey ME, Celio A, Manwaring ML, Kasten KR. Post-operative morbidity, but not mortality, is worsened by operative delay in septic diverticulitis. Int J Colorectal Dis 2017; 32:193-199. [PMID: 27815699 DOI: 10.1007/s00384-016-2689-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Optimal timing of surgery for acute diverticulitis remains unclear. A non-operative approach followed by elective surgery 6-week post-resolution is favored. However, a subset of patients fail on the non-operative management during index admission. Here, we examine patients requiring emergent operation to evaluate the effect of surgical delay on patient outcomes. METHODS Patients undergoing emergent operative intervention for acute diverticulitis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Primary endpoints of 30-day overall morbidity and mortality were evaluated via univariate and multivariate analysis. RESULTS Of the 2,119 patients identified for study inclusion, 57.2 % (n = 1212) underwent emergent operative intervention within 24 h, 26.3 % (n = 558) between days 1-3, 12.9 % (n = 273) between days 3-7, and 3.6 % (n = 76) greater than 7 days from admission. End colostomy was performed in 77.4 % (n = 1,640) of cases. Unadjusted age and presence of major comorbidities increased with operative delay. Further, unadjusted 30-day overall morbidity, mortality, septic complications, and post-operative length of stay increased significantly with operative delay. On multivariate analysis, operative delay was not associated with increased 30-day mortality but was associated with increased 30-day overall morbidity. CONCLUSIONS Hartmann's procedure has remained the standard operation in emergent surgical management of acute diverticulitis. Delay in definitive surgical therapy greater than 24 h from admission is associated with higher rates of morbidity and protracted post-operative length of stay, but there is no increase in 30-day mortality. Prospective study is necessary to further answer the question of surgical timing in acute diverticulitis.
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Affiliation(s)
- Anthony B Mozer
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Konstantinos Spaniolas
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Megan E Sippey
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Adam Celio
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Mark L Manwaring
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA
| | - Kevin R Kasten
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, 2MA234, Greenville, NC, 27834, USA.
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Chung BH, Ha GW, Lee MR, Kim JH. Management of Colonic Diverticulitis Tailored to Location and Severity: Comparison of the Right and the Left Colon. Ann Coloproctol 2016; 32:228-233. [PMID: 28119866 PMCID: PMC5256252 DOI: 10.3393/ac.2016.32.6.228] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 10/24/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose This study assessed optimal management of colonic diverticulitis as functions of disease location and severity and factors associated with complicated diverticulitis. Methods This retrospective review analyzed 202 patients diagnosed between 2007 and 2014 at Chonbuk National University Hospital, South Korea, with colonic diverticulitis by using abdominopelvic computed tomography. Diverticulitis location was determined, and disease severity was categorized using the modified Hinchey classification. Results Patients included 108 males (53.5%) and 94 females (46.5%); of these, 167 patients (82.7%) were diagnosed with right-sided and 35 (17.3%) with left-sided colonic diverticulitis. Of the 167 patients with right-sided colonic diverticulitis, 12 (7.2%) had complicated and 155 (92.8%) had uncomplicated diverticulitis; of these, 157 patients (94.0%) were successfully managed conservatively. Of the 35 patients with left-sided colonic diverticulitis, 23 (65.7%) had complicated and 12 (34.3%) had uncomplicated diverticulitis; of these, 23 patients (65.7%) were managed surgically. Among patients with right-sided diverticulitis, those with complicated disease were significantly older (54.3 ± 12.7 years vs. 42.5 ± 13.4 years, P = 0.004) and more likely to be smokers (66.7% vs. 32.9%, P = 0.027) than those with uncomplicated disease. However, among patients with left-sided diverticulitis, those with complicated disease had significantly lower body mass index (BMI; 21.9 ± 4.7 kg/m2 vs. 25.8 ± 4.3 kg/m2, P = 0.021) than those with uncomplicated disease. Conclusion Conservative management may be effective in patients with right-sided diverticulitis and patients with uncomplicated left-sided colonic diverticulitis. Surgical management may be required for patients with complicated left-sided diverticulitis. Factors associated with complicated diverticulitis include older age, smoking and lower BMI.
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Affiliation(s)
- Byeoung Hoon Chung
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Gi Won Ha
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Min Ro Lee
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jong Hun Kim
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Søreide K, Boermeester MA, Humes DJ, Velmahos GC. Acute colonic diverticulitis: modern understanding of pathomechanisms, risk factors, disease burden and severity. Scand J Gastroenterol 2016; 51:1416-1422. [PMID: 27539786 DOI: 10.1080/00365521.2016.1218536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Conservative, non-antibiotic and non-surgical management of acute diverticulitis is currently being investigated. To better inform clinical decisions, better understanding of disease mechanisms, disease burden and severity is needed. METHODS Literature search of risk factors, pathophysiology, epidemiology and disease burden/severity reported over the last decade. RESULTS Acute diverticulitis is a common disease and has a high disease burden. Incidence of hospital admissions is reported around 71 per 100,000 population, with reported increase in several subpopulations over the last decades. The incidence is likely to increase further with the aging populations. Risk factors for left-sided acute diverticulitis include dietary, anthropometric and lifestyle factors. Disease mechanisms are still poorly understood, but a distinction between inflammation and infection is emerging. The integrative and complex role of the gut microbiota has become an interesting factor for both understanding the disease as well as a potential target for intervention using probiotics. Mild, self-limiting events are increasingly reported from studies of successful non-antibiotic management in a considerable number of cases. Risk markers of progression to or presence of severe, complicated disease are needed for better disease stratification. Current risk stratification by clinical, imaging or endoscopic means is imperfect and needs validation. Long-term results from minimal-invasive and comparative surgical trials may better help inform clinicians and patients. CONCLUSIONS Over- and under-treatment as well as over- and under-diagnosis of severity is likely to continue in clinical practice due to lack of reliable, robust and universal severity and classification systems. Better understanding of pathophysiology is needed.
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Affiliation(s)
- Kjetil Søreide
- a Department of Gastrointestinal Surgery , Stavanger University Hospital , Stavanger , Norway.,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Marja A Boermeester
- c Department of Surgery , Academic Medical Center , Amsterdam , the Netherlands
| | - David J Humes
- d Division of Epidemiology and Public Health , School of Community Health Sciences, University of Nottingham , Nottingham , UK
| | - George C Velmahos
- e Division of Trauma Emergency Surgery and Surgical Critical Care , Massachusetts General Hospital , Boston , MA , USA.,f Harvard Medical School , Boston , MA , USA
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Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 2016; 35:201-208. [PMID: 27741423 DOI: 10.1016/j.ijsu.2016.10.006] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/30/2016] [Accepted: 10/08/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options. METHODS PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence. RESULTS Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain. CONCLUSIONS Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.
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Affiliation(s)
- Rasmus Gregersen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Laura Quitzau Mortensen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jakob Burcharth
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | | | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Abstract
Diverticular disease (DD) of the colon represents the most common disease affecting the large bowel in western countries. Its prevalence is increasing. Recent studies suggest that changes in gut microbiota could contribute to development of symptoms and complication. For this reason antibiotics play a key role in the management of both uncomplicated and complicated DD. Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated DD and to improve symptoms and maintain periods of remission following acute colonic diverticulitis (AD). Despite absence of data that supports the routine use of antibiotic in uncomplicated AD, they are recommended in selected patients. In patients with AD that develop an abscess, conservative treatment with broad-spectrum antibiotics is successful in up to 70% of cases. In patients on conservative treatment where percutaneous drainage fails or peritonitis develops, surgery is considered the standard therapy. In conclusion antibiotics seem to remain the mainstay of treatment in symptomatic uncomplicated DD and AD. Inpatient management and intravenous antibiotics are necessary in complicated AD, while outpatient management is considered the best strategy in the majority of uncomplicated patients.
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Horesh N, Wasserberg N, Zbar AP, Gravetz A, Berger Y, Gutman M, Rosin D, Zmora O. Changing paradigms in the management of diverticulitis. Int J Surg 2016; 33 Pt A:146-150. [PMID: 27494997 DOI: 10.1016/j.ijsu.2016.07.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/21/2016] [Accepted: 07/26/2016] [Indexed: 12/15/2022]
Abstract
The management of diverticular disease has evolved in the last few decades from a structured therapeutic approach including operative management in almost all cases to a variety of medical and surgical approaches leading to a more individualized strategy. There is an ongoing debate among surgeons about the surgical management of diverticular disease, questioning not only the surgical procedure of choice, but also about who should be operated and the timing of surgery, both in complicated and uncomplicated diverticular disease. This article reviews the current treatment of diverticulitis, with a focus on the indications and methods of surgery in both the emergency and elective settings. Further investigation with good clinical data is needed for the establishment of clear guidelines.
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Affiliation(s)
- Nir Horesh
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel.
| | - Nir Wasserberg
- Department of Surgery B, Rabin Medical Center, Petach Tikva 49100, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
| | - Aviad Gravetz
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
| | - Yaniv Berger
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
| | - Mordechai Gutman
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
| | - Danny Rosin
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
| | - Oded Zmora
- Department of Surgery and Transplantation, Chaim Sheba Medical Center Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University), Israel
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Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, Di Saverio S, Ulrych J, Kluger Y, Ben-Ishay O, Moore FA, Ivatury RR, Coimbra R, Peitzman AB, Leppaniemi A, Fraga GP, Maier RV, Chiara O, Kashuk J, Sakakushev B, Weber DG, Latifi R, Biffl W, Bala M, Karamarkovic A, Inaba K, Ordonez CA, Hecker A, Augustin G, Demetrashvili Z, Melo RB, Marwah S, Zachariah SK, Shelat VG, McFarlane M, Rems M, Gomes CA, Faro MP, Júnior GAP, Negoi I, Cui Y, Sato N, Vereczkei A, Bellanova G, Birindelli A, Di Carlo I, Kok KY, Gachabayov M, Gkiokas G, Bouliaris K, Çolak E, Isik A, Rios-Cruz D, Soto R, Moore EE. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 2016; 11:37. [PMID: 27478494 PMCID: PMC4966807 DOI: 10.1186/s13017-016-0095-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/26/2016] [Indexed: 02/06/2023] Open
Abstract
Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62019 Macerata, Italy
| | - Fausto Catena
- Department of Surgery, Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ofir Ben-Ishay
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Andrew B. Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca’Granda Hospital, Milan, Italy
| | - Jeffry Kashuk
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | - Dieter G. Weber
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW Australia
| | - Rifat Latifi
- Department of Surgery, Trauma Research Institute, University of Arizona, Tucson, AZ USA
| | - Walter Biffl
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Kenji Inaba
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA USA
| | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Goran Augustin
- Department of Surgery, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Renato Bessa Melo
- Department of General Surgery, Centro Hospitalar São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | | | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore, Singapore
| | - Michael McFarlane
- Department of Surgery, Radiology, Anaesthetics and Intensive Care, University Hospital of the West Indies, Kingston, Jamaica
| | - Miran Rems
- Surgical Department, General Hospital Jesenice, Jesenice, Slovenia
| | - Carlos Augusto Gomes
- Federal University of Juiz de Fora (UFJF) AND Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, MG Brazil
| | - Mario Paulo Faro
- Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira Júnior
- Emergency Surgery and Trauma Unit, Department of Surgery, University of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Ionut Negoi
- Emergency Hospital of Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Norio Sato
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | | | | | - Isidoro Di Carlo
- Department of Surgical Sciences, Organs Transplantation and Advanced Technologies, “G.F. Ingrassia” University of Catania, Cannizzaro Hospital, Catania, Italy
| | - Kenneth Y Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Mahir Gachabayov
- Department of Surgery, Clinical Hospital of Emergency Medicine, Vladimir City, Russian Federation
| | - Georgios Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Elif Çolak
- Department of Surgery, Samsun Education and Research Hospital, Samsun, Turkey
| | - Arda Isik
- Department of Surgery, Mengucek Gazi Training Research Hospital, Erzincan, Turkey
| | - Daniel Rios-Cruz
- Department of Surgery, Hospital de Alta Especialidad de Veracruz, Veracruz, Mexico
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
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Abstract
BACKGROUND Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear. OBJECTIVE The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess. DESIGN This was a retrospective chart review with prospective telephone follow-up of patients. SETTINGS The study was conducted at a large tertiary academic colorectal surgery practice in Canada. PATIENTS Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included. INTERVENTIONS Long-term definitive nonoperative management of diverticular abscess. MAIN OUTCOME MEASURES The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis. RESULTS Of 135 patients with acute diverticulitis complicated by abscess, a total of 73 patients were managed with nonoperative intent and long-term expectant management. The median follow-up was 62 (Q1 to Q3: 28-98) months. After resolution of the index episode, 22 patients [30.1% (95% CI, 19.6%-40.6%)] experienced a recurrent episode of diverticulitis at a median of 23 (range, 9-40) months. Two patients [2.7% (95% CI, -1.0% to 6.4%)] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months. Both patients underwent reversal after 4 and 8 months. Seven [9.6% (95% CI, 2.8%-16.4%)] patients experienced a complicated recurrence and underwent an elective sigmoidectomy [median time to colectomy, 33 (range, 16-56) months]. Thirteen patients [17.8% (95% CI, 9.0%-26.6%)] experienced an uncomplicated recurrence, all of whom were managed with continued nonoperative intent [median follow-up, 81 (range, 34-115) months]. No mortality occurred. On multivariate logistic regression, female gender (p = 0.048) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess (p = 0.020) were associated with a recurrent episode. LIMITATIONS This study was limited by its retrospective design and modest sample size. CONCLUSIONS After initial successful nonoperative management of diverticulitis with abscess, expectant management with nonoperative intent is a safe long-term option with low rates of surgery, especially in the emergency setting. See Video, Supplemental Digital Content 1, on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234.
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Abstract
Acute diverticulitis occurs in up to 25% of patients with diverticulosis. The majority of cases are mild or uncomplicated and it has become a frequent reason for consultation in the emergency department. On the basis of the National Inpatient Sample database from the USA, 86% of patients admitted with diverticulitis were treated with medical therapy. However, several recent studies have shown that outpatient treatment with antibiotics is safe and effective. The aim of this systematic review is to update the evidence published in the outpatient treatment of uncomplicated acute diverticulitis. We performed a systematic review according to the PRISMA guidelines and searched in MEDLINE and Cochrane databases all English-language articles on the management of acute diverticulitis using the following search terms: 'diverticulitis', 'outpatient', and 'uncomplicated'. Data were extracted independently by two investigators. A total of 11 articles for full review were yielded: one randomized controlled trial, eight prospective cohort studies, and two retrospective cohort studies. Treatment successful rate on an outpatient basis, which means that no further complications were reported, ranged from 91.5 to 100%. Fewer than 8% of patients were readmitted in the hospital. Intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and economically efficient when applying an appropriate selection in most reviewed studies.
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Abstract
OBJECTIVE To determine the impact of elective colectomy on emergency diverticulitis surgery at the population level. BACKGROUND Current recommendations suggest avoiding elective colon resection for uncomplicated diverticulitis because of uncertain effectiveness at reducing recurrence and emergency surgery. The influence of these recommendations on use of elective colectomy or rates of emergency surgery remains undetermined. METHODS A retrospective cohort study using a statewide hospital discharge database identified all patients admitted for diverticulitis in Washington State (1987-2012). Sex- and age-adjusted rates (standardized to the 2000 state census) of admissions, elective and emergency/urgent surgical and percutaneous interventions for diverticulitis were calculated and temporal changes assessed. RESULTS A total of 84,313 patients (mean age 63.3 years and 58.9% female) were hospitalized for diverticulitis (72.2% emergent/urgent). Elective colectomy increased from 7.9 to 17.2 per 100,000 people (P < 0.001), rising fastest since 2000. Emergency/urgent colectomy increased from 7.1 to 10.2 per 100,000 (P < 0.001), nonelective percutaneous interventions increased from 0.1 to 3.7 per 100,000 (P = 0.04) and the frequency of emergency/urgent admissions (with or without a resection) increased from 34.0 to 85.0 per 100,000 (P < 0.001). In 2012, 47.5% of elective resections were performed laparoscopically compared to 17.5% in 2008 (when the code was introduced). CONCLUSIONS The elective colectomy rate for diverticulitis more than doubled, without a decrease in emergency surgery, percutaneous interventions, or admissions for diverticulitis. This may reflect changes in thresholds for elective surgery and/or an increase in the frequency or severity of the disease. These trends do not support the practice of elective colectomy to prevent emergency surgery.
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Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach? Tech Coloproctol 2016; 20:309-315. [PMID: 27053254 DOI: 10.1007/s10151-016-1464-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 02/27/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND A growing body of knowledge is calling into question the use of antibiotics in acute diverticulitis (AD). Moreover, recent studies provide evidence regarding the security of treating patients with AD as outpatients. The aim of this study was to evaluate a restrictive antibiotic outpatient protocol for the treatment of mild-to-moderate episodes of AD. METHODS All patients with symptoms of AD presenting to our emergency department were assigned a modified Neff stage. Patients with mild AD received outpatient treatment without antibiotics. Patients with mild AD and comorbidities were admitted to receive the same treatment. Patients with moderate AD were admitted for 48 h and were then managed as outpatients until they had completed 10 days of antibiotic treatment. RESULTS Between April 2013 and November 2014, we attended 110 patients with a diagnosis of AD, 77 of whom we included in the study: 45 patients with mild AD and 32 with moderate AD. Of the patients with mild AD, 88.8 % successfully completed the non-antibiotic, non-admission treatment regime and 95.5 % benefited from a non-antibiotic regime, whether as outpatients or inpatients. A total of 88 % of patients with mild AD and 87.5 % of patients with moderate AD who met the inclusion criteria completed treatment as outpatients without incident. No major complications (abscess, emergency surgery) or deaths were recorded. CONCLUSIONS Outpatient treatment without antibiotics for patients with mild AD is safe and effective. Patients with moderate AD can be safely treated with antibiotics in a mixed regime as inpatients and outpatients.
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Dréanic J, Sion E, Dhooge M, Dousset B, Camus M, Chaussade S, Coriat R. Traitement de la diverticulite aiguë sigmoïdienne : revue de la littérature. JOURNAL EUROPÉEN DES URGENCES ET DE RÉANIMATION 2016; 28:26-38. [DOI: 10.1016/j.jeurea.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Tan JPL, Barazanchi AWH, Singh PP, Hill AG, Maccormick AD. Predictors of acute diverticulitis severity: A systematic review. Int J Surg 2016; 26:43-52. [PMID: 26777741 DOI: 10.1016/j.ijsu.2016.01.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/14/2015] [Accepted: 01/06/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis. METHODS A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death. RESULTS Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity. CONCLUSION A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.
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Affiliation(s)
- James P L Tan
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ahmed W H Barazanchi
- Department of Surgery, Lower Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand.
| | - Primal P Singh
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Andrew D Maccormick
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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Gargallo Puyuelo CJ, Sopeña F, Lanas Arbeloa A. Colonic diverticular disease. Treatment and prevention. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:590-9. [PMID: 25979437 DOI: 10.1016/j.gastrohep.2015.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/06/2015] [Accepted: 03/11/2015] [Indexed: 02/07/2023]
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Buchs NC, Mortensen NJ, Ris F, Morel P, Gervaz P. Natural history of uncomplicated sigmoid diverticulitis. World J Gastrointest Surg 2015; 7:313-318. [PMID: 26649154 PMCID: PMC4663385 DOI: 10.4240/wjgs.v7.i11.313] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/31/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
While diverticular disease is extremely common, the natural history (NH) of its most frequent presentation (i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to population-based or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein > 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon > 5 cm. The risk of developing a complicated second episode (and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.
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Abstract
INTRODUCTION The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). METHODS This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. RESULTS Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach. CONCLUSIONS Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported.
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Affiliation(s)
- L Genser
- Service de chirurgie digestive, hôpital Jean-Verdier, AP-HP, hôpitaux universitaires de Seine-Saint-Denis, avenue du 14 Juillet, 93140 Bondy, France
| | - C Vons
- Service de chirurgie digestive, hôpital Jean-Verdier, AP-HP, hôpitaux universitaires de Seine-Saint-Denis, avenue du 14 Juillet, 93140 Bondy, France.
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[Treatment of the acute diverticulitis: A systematic review]. Presse Med 2015; 44:1113-25. [PMID: 26358668 DOI: 10.1016/j.lpm.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/23/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023] Open
Abstract
Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.
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Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. Int J Colorectal Dis 2015; 30:1229-34. [PMID: 25989930 DOI: 10.1007/s00384-015-2258-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period. METHODS A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months. RESULTS In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4%) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6%) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients. CONCLUSION Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.
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Jaung R, Robertson J, Vather R, Rowbotham D, Bissett IP. Changes in the approach to acute diverticulitis. ANZ J Surg 2015. [DOI: 10.1111/ans.13233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Rebekah Jaung
- Department of Surgery; The University of Auckland; Auckland New Zealand
| | - Jason Robertson
- Department of Surgery; The University of Auckland; Auckland New Zealand
| | - Ryash Vather
- Department of Surgery; The University of Auckland; Auckland New Zealand
| | - David Rowbotham
- Department of Gastroenterology and Hepatology; Auckland City Hospital; Auckland New Zealand
| | - Ian P. Bissett
- Department of Surgery; The University of Auckland; Auckland New Zealand
- Department of Surgery; Auckland City Hospital; Auckland New Zealand
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Mäkelä JT, Klintrup K, Takala H, Rautio T. The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit. Scand J Gastroenterol 2015; 50:536-41. [PMID: 25665622 DOI: 10.3109/00365521.2014.999350] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Computed tomography (CT) is the most appropriate initial imaging modality for the assessment of acute diverticulitis. The aim here was to determine the usefulness of C-reactive protein (CRP) in predicting the severity of the diverticulitis process and the need for a CT examination. METHODS The CRP values of 350 patients who presented first time with symptoms of acute diverticulitis and underwent CT imaging on admission to Oulu University Hospital were compared with the CT findings and clinical parameters by means of both univariate and multivariate analyses. RESULTS The receiver operating characteristic curve showed that a CRP cut-off value of 149.5 mg/l significantly discriminated acute uncomplicated diverticulitis from complicated diverticulitis (specificity 65%, sensitivity 85%, area under the curve 0.811, p = 0.0001). In multivariate analysis, a CRP value over 150 mg/l and old age were independent risk factors for acute complicated diverticulitis. The mean CRP value was significantly higher in the patients who died, 207 (84 SD), than in those who survived, 139 (SD 83). In addition, a CRP value over 150 mg/l and free abdominal fluid in CT were independent variables predicting postoperative mortality. CONCLUSIONS CRP is useful for the predicting the severity of acute diverticulitis on admission. Patients with a CRP value higher than 150 mg/l have an in increased risk of complicated diverticulitis and a CT examination should always be carried out.
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Affiliation(s)
- Jyrki T Mäkelä
- Department of Surgery, Oulu University Hospital, Division of Gastroenterology , Kajaanintie 50, 90220 Oulu , Finland
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Ha GW, Lee MR, Kim JH. Efficacy of conservative management in patients with right colonic diverticulitis. ANZ J Surg 2015; 87:467-470. [PMID: 25786747 DOI: 10.1111/ans.13028] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although right colonic diverticulitis is more common than sigmoid diverticulitis, and its incidence has been increasing in Asian countries, there is no definitive treatment strategy for right colonic diverticulitis. This retrospective clinical study assessed the effect of conservative management in patients with right colonic diverticulitis. METHODS Of the 169 patients who were diagnosed with right colonic diverticulitis at Chonbuk National University Hospital, South Korea, from 2005 to 2012, 152 patients evaluated by abdominopelvic computed tomography (CT) and managed conservatively were included. CT findings were categorized by modified Hinchey classification, with stages Ib, II, III and IV, as well as fistula and obstruction defined as complicated diverticulitis. Factors associated with recurrence of diverticulitis were determined. RESULTS The mean age of 152 patients (87 males, 65 females) was 42.9 ± 13.8 years, median follow-up interval was 61 months (range, 17-113 months). At diagnosis, five patients (3.3%) had complicated diverticulitis. After treatment of first attack, 15 patients (9.9%) experienced recurrence of right colonic diverticulitis, including 10 (6.6%) within 12 months. Fourteen of these patients were successfully treated conservatively, whereas one failed conservative management and required surgical resection. Statistical analysis found no variables related to recurrence of right colonic diverticulitis. CONCLUSION Right colonic diverticulitis has a low rate of complicated diverticulitis at first attack and a low recurrence rate, with most recurrences being uncomplicated. Therefore, conservative management is effective in patients with right colonic diverticulitis. Close follow-up of patients for 12 months is required because most recurrences may occur within 12 months.
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Affiliation(s)
- Gi Won Ha
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Jeonbuk, South Korea
| | - Min Ro Lee
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Jeonbuk, South Korea
| | - Jong Hun Kim
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Jeonbuk, South Korea
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Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F, Griffiths EA, Coimbra R, Agresta F, Sakakushev B, Ordoñez CA, Abu-Zidan FM, Karamarkovic A, Augustin G, Costa Navarro D, Ulrych J, Demetrashvili Z, Melo RB, Marwah S, Zachariah SK, Wani I, Shelat VG, Kim JI, McFarlane M, Pintar T, Rems M, Bala M, Ben-Ishay O, Gomes CA, Faro MP, Pereira GA, Catani M, Baiocchi G, Bini R, Anania G, Negoi I, Kecbaja Z, Omari AH, Cui Y, Kenig J, Sato N, Vereczkei A, Skrovina M, Das K, Bellanova G, Di Carlo I, Segovia Lohse HA, Kong V, Kok KY, Massalou D, Smirnov D, Gachabayov M, Gkiokas G, Marinis A, Spyropoulos C, Nikolopoulos I, Bouliaris K, Tepp J, Lohsiriwat V, Çolak E, Isik A, Rios-Cruz D, Soto R, Abbas A, Tranà C, Caproli E, Soldatenkova D, Corcione F, Piazza D, Catena F. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg 2015; 10:3. [PMID: 25972914 PMCID: PMC4429354 DOI: 10.1186/1749-7922-10-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/30/2014] [Indexed: 02/08/2023] Open
Abstract
Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis. The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.
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Affiliation(s)
| | | | - Luca Ansaloni
- />General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | | | - Ewen A Griffiths
- />Department of Surgery, Queen Elizabeth Hospital, Birminham, UK
| | - Raul Coimbra
- />Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ferdinando Agresta
- />Department of Surgery, Ospedale Civile, ULSS19 del Veneto, Adria, (RO) Italy
| | - Boris Sakakushev
- />First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Carlos A Ordoñez
- />Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Fikri M Abu-Zidan
- />Department of Surgery, Faculty of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Goran Augustin
- />Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - David Costa Navarro
- />General and Digestive Tract Surgery, Alicante University General Hospital, Alicante, Spain
| | - Jan Ulrych
- />1st Surgical Department of First Faculty of Medicine, General University Hospital, Prague Charles University, Prague, Czech Republic
| | - Zaza Demetrashvili
- />Department of General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Renato B Melo
- />Department of General Surgery, Centro Hospitalar São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sanjay Marwah
- />Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | | | - Imtiaz Wani
- />Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Vishal G Shelat
- />Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Jae Il Kim
- />Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Michael McFarlane
- />Department of Surgery, Radiology, Anaesthetics and Intensive Care University Hospital of the West Indies, Kingston, Jamaica
| | - Tadaja Pintar
- />Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Miran Rems
- />Surgical Department, General Hospital Jesenice, Jesenice, Slovenia
| | - Miklosh Bala
- />Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Offir Ben-Ishay
- />Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Carlos Augusto Gomes
- />Federal University of Juiz de Fora (UFJF) AND Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, MG Brazil
| | - Mario Paulo Faro
- />Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira
- />Emergency Surgery and trauma Unit, Department of Surgery, Ribeirão, Preto, Brazil
| | - Marco Catani
- />DEA, Umberto I University Hospital, Rome, Italy
| | - Gianluca Baiocchi
- />Clinical and Experimental Sciences, Brescia Ospedali Civili, Brescia, Italy
| | - Roberto Bini
- />General and Emergency Surgery SG Bosco Hospital, Turin, Italy
| | - Gabriele Anania
- />Department of Surgery, Arcispedale S. Anna, Medical University of Ferrara, Ferrara, Italy
| | - Ionut Negoi
- />Emergency Hospital of Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Zurabs Kecbaja
- />General and Emergency Surgery Department, Riga East University Hospital “Gailezers”, Riga, Latvia
| | - Abdelkarim H Omari
- />Department of General Surgery, King Abdalla University Hospital, Irbid, Jordan
| | - Yunfeng Cui
- />Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Jakub Kenig
- />3rd Department of Generał Surgery, Narutowicz Hospital, Krakow, Połand
| | - Norio Sato
- />Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Andras Vereczkei
- />Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Matej Skrovina
- />Department of Surgery Hospital and Oncological Centre Novy Jicin, Novy Jicin, Czech Republic
| | - Koray Das
- />Department of General Surgery, Numune Training and Research Hospital, Adana, Turkey
| | | | | | | | - Victor Kong
- />Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Kenneth Y Kok
- />Department of Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei
| | - Damien Massalou
- />Department of Surgery, University Hospital of Nice, University of Nice Sophia-Antipolis, Sophia-Antipolis, France
| | - Dmitry Smirnov
- />Department of Surgical Diseases, South Ural State Medical University, Chelyabinsk City, Russian Federation
| | - Mahir Gachabayov
- />Department of Surgery, Clinical Hospital of Emergency Medicine, Vladimir City, Russian Federation
| | - Georgios Gkiokas
- />2nd Department of Surgery, Aretaieio University Hospital, Athens, Greece
| | - Athanasios Marinis
- />First Department of Surgery, Tzanion General Hospital, Piraeus, Greece
| | | | | | | | - Jaan Tepp
- />Department of General Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Varut Lohsiriwat
- />Department of Surgery, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand
| | - Elif Çolak
- />Department of Surgery, Samsun Education and Research Hospital, Samsun, Turkey
| | - Arda Isik
- />Department of Surgery, Mengucek Gazi Training Research Hospital, Erzincan, Turkey
| | - Daniel Rios-Cruz
- />Department of Surgery, Hospital de Alta Especialidad de Veracruz, Veracruz, Mexico
| | - Rodolfo Soto
- />Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Ashraf Abbas
- />Emergency Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Cristian Tranà
- />Department of Emergency Medicine and Surgery, Macerata Hospital, Macerata, Italy
| | | | - Darija Soldatenkova
- />General and Emergency Surgery Department, Riga East University Hospital “Gailezers”, Riga, Latvia
| | - Francesco Corcione
- />Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Diego Piazza
- />Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Fausto Catena
- />Emergency Department, Maggiore University Hospital, Parma, Italy
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Lamb MN, Kaiser AM. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis Colon Rectum 2014; 57:1430-1440. [PMID: 25380010 DOI: 10.1097/dcr.0000000000000230] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous drainage followed by delayed resection. Controversy has arisen regarding the necessity of elective surgery, when nonoperative management has successfully resolved the index attack. OBJECTIVE The aim of this systematic review was to analyze the literature to determine the recurrence rate in those patients who were successfully managed nonoperatively and determine the role of elective surgical resection. DATA SOURCES An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews performed from 1986 to 2014. The search terms used were as follows: "diverticulitis," "abscess," "diverticular abscess," "percutaneous drainage," and "surgery." STUDY SELECTION Studies included for review evaluated the management of diverticular abscesses and the subsequent role of delayed elective resection. INTERVENTIONS All of the studies were systematically reviewed and underwent a meta-analysis. MAIN OUTCOME MEASURES End points were the need for surgery and recurrent attacks without surgery. RESULTS Twenty-two studies reporting a total of 1051 patients with acute diverticulitis with abscess formation (modified Hinchey grades IB and II) were included in the review. Percutaneous drainage was successful in 49% patients (diameter, >3 cm) and antibiotic therapy in 14% patients. Urgent surgery during the index hospitalization was performed in 30% of patients, elective resection in 36%, and no surgery in 35%. Recurrence rates were high, with 39% in patients awaiting elective resection and 18% in the nonsurgery group, with an overall recurrence rate of 28%. Of the whole cohort, only 28% had no surgery and no recurrence during follow-up. LIMITATIONS Sample size, heterogeneity, selection and treatment bias, and limited follow-up of included studies were limitations to this study. CONCLUSIONS The evidence from the literature is weak but still suggests that complicated diverticulitis with abscess formation is associated with a high probability of resective surgery, whereas conservative management may result in chronic or recurrent diverticular symptoms.
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Affiliation(s)
- M Nicole Lamb
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angles, California
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76
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Simianu VV, Flum DR. Rethinking elective colectomy for diverticulitis: A strategic approach to population health. World J Gastroenterol 2014; 20:16609-16614. [PMID: 25469029 PMCID: PMC4248204 DOI: 10.3748/wjg.v20.i44.16609] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/15/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient “episode counting” a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to “individualize” decisions for elective colectomy and there is an international focus on “appropriate” indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-442. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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Park HC, Kim BS, Lee K, Kim MJ, Lee BH. Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack. Int J Colorectal Dis 2014; 29:1217-22. [PMID: 24980689 DOI: 10.1007/s00384-014-1941-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Most patients with acute right colonic uncomplicated diverticulitis can be managed conservatively. The aim of this study was to assess the clinical and radiologic risk factors for recurrence in patients with right colonic uncomplicated diverticulitis. METHODS The present survey included 469 patients who were successfully managed conservatively for the first episode of right colonic uncomplicated diverticulitis between 2002 and 2012 in a referral center, and records were reviewed from collected data. Patients were divided into two groups: a nonrecurrent and a recurrent group. The clinical and radiologic features of all patients were analyzed to identify possible risk factors for recurrence. The Kaplan-Meier method and Cox regression were used. RESULTS Seventy-four (15.8 %) patients had recurrence, and 15 (3.2 %) received surgery at recurrence within a median follow-up of 59 months. The mean recurrence interval after the first attack was 29 months. In univariate and multivariate analyses, risk factors for recurrence were confirmed multiple diverticula (relative risk [RR], 2.62; 95 % confidence interval [CI], 1.56-4.40) and intraperitoneally located diverticulitis (RR, 3.73; 95 % CI, 2.13-6.52). Of 66 patients with two risk factors, 36 (54.5 %) had recurrence and 10 (15.2 %) received surgery at recurrence. CONCLUSIONS In patients with right colonic uncomplicated diverticulitis who have multiple diverticula and intraperitoneally located diverticulitis, the possibility of recurrence and surgical rate are high. Poor outcome may be cautioned in these patients.
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Affiliation(s)
- Hyoung-Chul Park
- Department of Surgery, Hallym University College of Medicine, 896 Pyeongchon-dong, Dongan-gu, Anyang, 431-070, Republic of Korea
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Abstract
BACKGROUND AND OBJECTIVES A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula. METHODS A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period. RESULTS Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence. CONCLUSIONS Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.
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Affiliation(s)
| | - Anna T Tsay
- Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA
| | - Maher A Abbas
- Chair, Minimally Invasive and Robotic Surgery, 4760 Sunset Boulevard, Third Floor, Los Angeles, CA 90027, USA.
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80
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Tursi A, Elisei W, Picchio M, Brandimarte G. Increased faecal calprotectin predicts recurrence of colonic diverticulitis. Int J Colorectal Dis 2014; 29:931-5. [PMID: 24798630 DOI: 10.1007/s00384-014-1884-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Colonic diverticulitis shows a high recurrence rate, but the role of faecal markers in predicting recurrence is unknown. The aim of this study was to investigate the role of faecal calprotectin (FC) in predicting recurrence of diverticulitis. PATIENTS/METHODS A prospective cohort study was performed on 54 patients suffering from acute uncomplicated diverticulitis (AUD) diagnosed by computerized tomography (CT). After remission, patients underwent to clinical follow-up every 2 months. After remission and during the follow-up, FC was analysed. Recurrence of diverticulitis was defined as return to our observation due to left lower-quadrant pain with or without other symptoms (e.g. fever), associated with leucocytosis and/or increased C-reactive protein (CRP). Presence of diverticulitis was confirmed by means of CT. RESULTS/FINDINGS The mean follow-up was 20 months (range 12-24 months). Forty-eight patients were available for the final evaluation, and six patients were lost to follow-up. During follow-up, increased FC was detected in 17 (35.4 %) patients and diverticulitis recurred in eight patients (16.7 %). Diverticulitis recurred in eight (16.7 %) patients: seven (87.5 %) patients showed increased FC during the follow-up, and only one (12.5 %) patient with recurrent diverticulitis did not show increased FC. Diverticulitis recurrence was strictly related to the presence of abnormal FC test during follow-up. CONCLUSIONS In the present prospective study, increased FC was found to be predictive of diverticulitis recurrence.
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Affiliation(s)
- Antonio Tursi
- Gastroenterology Service, ASL BAT, Via Torino, 49, 76123, Andria, BT, Italy,
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81
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Jackson JD, Hammond T. Systematic review: outpatient management of acute uncomplicated diverticulitis. Int J Colorectal Dis 2014; 29:775-81. [PMID: 24859874 DOI: 10.1007/s00384-014-1900-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach. METHODS Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion. RESULTS Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %. CONCLUSION Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.
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Affiliation(s)
- J D Jackson
- Barts and The London School of Medicine and Dentistry, London, UK,
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82
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Tursi A. Efficacy, safety, and applicability of outpatient treatment for diverticulitis. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:29-36. [PMID: 24729730 PMCID: PMC3976207 DOI: 10.2147/dhps.s61277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Although current guidelines recommend use of antibiotics for the outpatient treatment of acute uncomplicated diverticulitis, evidence for this is still lacking. Hence, significant effort is now being made to identify the appropriate therapeutic approach to treat and prevent relapses of diverticulitis. Outpatient treatment has been identified as a safe and effective therapeutic approach in up to 90% of patients with uncomplicated diverticulitis. It allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.
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83
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Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2014; 259:38-44. [PMID: 23732265 DOI: 10.1097/sla.0b013e3182965a11] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs. BACKGROUND The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States. METHODS This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs. RESULTS A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P=0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of €1124.70 per patient. No differences were observed between the groups in terms of quality of life. CONCLUSIONS Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.
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84
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Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57:284-294. [PMID: 24509449 DOI: 10.1097/dcr.0000000000000075] [Citation(s) in RCA: 385] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Feingold
- Prepared by the Clinical Practice Guideline Task Force of the American Society of Colon and Rectal Surgeons
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85
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Humes DJ, Spiller RC. Review article: The pathogenesis and management of acute colonic diverticulitis. Aliment Pharmacol Ther 2014; 39:359-70. [PMID: 24387341 DOI: 10.1111/apt.12596] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 07/18/2013] [Accepted: 12/09/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute diverticulitis, defined as acute inflammation associated with a colonic diverticulum, is a common emergency presentation managed by both surgeons and physicians. There have been advances in both the medical and the surgical treatments offered to patients in recent years. AIM To review the current understanding of the aetiology and treatment of acute diverticulitis. METHODS A search of PubMed and Medline databases was performed to identify articles relevant to the aetiology, pathogenesis and management of acute diverticulitis. RESULTS There are 75 hospital admissions per year for acute diverticulitis per 100,000 of the population in the United States. Recent reports suggest a 26% increase in admissions over a 7-year period. Factors predisposing to the development of acute diverticulitis include obesity, smoking, diet, lack of physical activity and medication use such as aspirin and nonsteroidal anti-inflammatory drugs. The condition is associated with a low mortality of about 1% following medical therapy, rising to 4% in-hospital mortality in those requiring surgery. There is limited evidence on the efficacy of individual antibiotic regimens, and antibiotic treatment may not be required in all patients. The rates of recurrence reported for patients with acute diverticulitis following medical management vary from 13% to 36%. The surgical management of those patients who fail medical treatment has moved towards a laparoscopic nonresectional approach; however, the evidence supporting this is limited. CONCLUSIONS Further high-quality randomised controlled trials are required of both medical and surgical treatments in patients with acute diverticulitis, if management is to be evidence-based.
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Affiliation(s)
- D J Humes
- Nottingham Digestive Diseases Centre and Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK
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86
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McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2013; 101:e90-9. [PMID: 24258427 DOI: 10.1002/bjs.9359] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. METHODS A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). RESULTS Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. CONCLUSION The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.
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Affiliation(s)
- F D McDermott
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park Dublin 4, Ireland
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87
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Mora Lopez L, Serra Pla S, Serra-Aracil X, Ballesteros E, Navarro S. Application of a modified Neff classification to patients with uncomplicated diverticulitis. Colorectal Dis 2013; 15:1442-7. [PMID: 24192258 DOI: 10.1111/codi.12449] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/07/2013] [Indexed: 02/06/2023]
Abstract
AIM Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. METHOD All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. RESULTS Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. CONCLUSION Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.
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Affiliation(s)
- L Mora Lopez
- Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), Sabadell, Spain
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Tursi A, Brandimarte G, Elisei W, Picchio M, Forti G, Pianese G, Rodino S, D'Amico T, Sacca N, Portincasa P, Capezzuto E, Lattanzio R, Spadaccini A, Fiorella S, Polimeni F, Polimeni N, Stoppino V, Stoppino G, Giorgetti GM, Aiello F, Danese S. Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease--a double-blind, randomised, placebo-controlled study. Aliment Pharmacol Ther 2013; 38:741-751. [PMID: 23957734 DOI: 10.1111/apt.12463] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Placebo-controlled studies in maintaining remission of symptomatic uncomplicated diverticular disease (SUDD) of the colon are lacking. AIM To assess the effectiveness of mesalazine and/or probiotics in maintaining remission in SUDD. METHODS A multicentre, double-blind, placebo-controlled study was conducted. Two hundred and ten patients were randomly enrolled in a double-blind fashion in four groups: Group M (active mesalazine 1.6 g/day plus Lactobacillus casei subsp. DG placebo), Group L (active Lactobacillus casei subsp. DG 24 billion/day plus mesalazine placebo), Group LM (active Lactobacillus casei subsp. DG 24 billion/day plus active mesalazine), Group P (Lactobacillus casei subsp. DG placebo plus mesalazine placebo). Patients received treatment for 10 days/month for 12 months. Recurrence of SUDD was defined as the reappearance of abdominal pain during follow-up, scored as ≥5 (0: best; 10: worst) for at least 24 consecutive hours. RESULTS Recurrence of SUDD occurred in no (0%) patient in group LM, in 7 (13.7%) patients in group M, in 8 (14.5%) patients in group L and in 23 (46.0%) patients in group P (LM group vs. M group, P = 0.015; LM group vs. L group, P = 0.011; LM group vs. P group, P = 0.000; M group vs. P group, P = 0.000; L group vs. P group, P = 0.000). Acute diverticulitis occurred in six group P cases and in one group L case (P = 0.003). CONCLUSION Both cyclic mesalazine and Lactobacillus casei subsp. DG treatments, particularly when given in combination, appear to be better than placebo for maintaining remission of symptomatic uncomplicated diverticular disease. (ClinicalTrials.gov: NCT01534754).
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Affiliation(s)
- A Tursi
- Gastroenterology Service, ASL BAT, Andria (BT), Italy.
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van de Wall BJM, Draaisma WA, van Iersel JJ, van der Kaaij R, Consten ECJ, Broeders IAMJ. Dietary restrictions for acute diverticulitis: evidence-based or expert opinion? Int J Colorectal Dis 2013; 28:1287-93. [PMID: 23604409 DOI: 10.1007/s00384-013-1694-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Diet restrictions are usually advised as part of the conservative treatment for the acute phase of a diverticulitis episode. To date, the rationale behind diet restrictions has never been thoroughly studied. This study aims to investigate which factors influence the choice of dietary restriction at presentation. Additionally, the effect of dietary restrictions on hospitalization duration is investigated. METHODS All patients hospitalized for Hinchey 0, Ia, or Ib diverticulitis between January 2010 and June 2011 were included. Patients were categorized according to the diet imposed by the treating physician at presentation and included nil per os, clear liquid, liquid diet, and solid foods. The relation between Hinchey classification, C-reactive protein, leucocyte count and temperature at presentation and diet choice was examined. Subsequently, the relation between diet restriction and number of days hospitalized was studied. RESULTS Of the 256 patients included in the study 65 received nil per os, 89 clear liquid, 75 liquid diet, and 27 solid foods at presentation. Solely high temperature appeared to be related to a more restrictive diet choice at presentation. Patients who received liquid diet (HR 1.66 CI 1.19-2.33) or solid foods (HR 2.39 CI 1.52-3.78) were more likely to be discharged compared to patient who received clear liquid diet (HR 1.26 CI 1.52-3.78) or nils per os (reference group). This relation remained statistically significant after correction for disease severity, treatment and complications. CONCLUSION Physicians appeared to prefer a more restrictive diet with increasing temperature at presentation. Notably, dietary restrictions prolong hospital stay.
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Affiliation(s)
- Bryan J M van de Wall
- Department of Surgery, Meander Medical Centre Amersfoort, Utrechtseweg 160, P.O. Box 1502, 3800 BM 3818 ES Amersfoort, The Netherlands
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Abstract
BACKGROUND Traditionally, treatment of acute diverticulitis has mostly been based on inpatient care. The question arises whether these patients can be treated on an outpatient basis as the admissions for diverticular disease have been shown to be increasing every year. We studied whether outpatient treatment of acute uncomplicated diverticulitis is feasible and safe, and which patients could benefit from outpatient care. MATERIALS AND METHODS A retrospective cohort study was carried out in two teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute uncomplicated diverticulitis between January 2004 and January 2012, confirmed by imaging or colonoscopy, were included. Exclusion criteria were patients with recurrent diverticulitis, complicated diverticulitis (Hinchey stages 2, 3, and 4), and right-sided diverticulitis. Inpatient care was compared with outpatient care. Primary outcome was admission for outpatient care and the complication rate in both groups. Multivariate analysis was carried out to identify potential factors for inpatient care. RESULTS Of 627 patients with diverticulitis, a total of 312 consecutive patients were identified with primary uncomplicated diverticulitis of the sigmoid colon; 194 patients had been treated as inpatients and 118 patients primarily as outpatients. In this last group, 91.5% had been treated successfully without diverticulitis-related complications or the need for hospital admission during a mean follow-up period of 48 months. CONCLUSION Despite inherent patient selection in a retrospective cohort, ambulatory treatment of patients presenting with uncomplicated acute diverticulitis seems feasible and safe. In mildly ill and younger patients, hospital admission can be avoided.
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91
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Rodríguez-Cerrillo M, Poza-Montoro A, Fernandez-Diaz E, Matesanz-David M, Iñurrieta Romero A. Treatment of elderly patients with uncomplicated diverticulitis, even with comorbidity, at home. Eur J Intern Med 2013; 24:430-2. [PMID: 23623263 DOI: 10.1016/j.ejim.2013.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 03/22/2013] [Accepted: 03/23/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Elderly patients with uncomplicated diverticulitis are usually hospitalized. The aim of this study is to compare the outcomes of elderly patients with uncomplicated diverticulitis who were treated at home versus traditional Hospitalization. METHODS Prospective study from March 2011 to September 2012 including patients over 70 years with uncomplicated diverticulitis admitted to Hospital at Home Unit and to Conventional Hospitalization from the Emergency Department. Patients with β-lactam allergy or who required admission to Conventional Hospitalization for other pathology were excluded. All patients were given intravenous antibiotic. Patients transferred to Hospital at Home stayed 24h in the Observation Ward within the Emergency Department prior to discharge. Characteristics and outcomes of patients are analyzed. RESULTS 34 patients were treated at home and 18 in hospital. Mean age was similar in both groups (77 vs 79). The oldest patient treated at home was 90 years old. 64% of patients treated in Hospital at Home had comorbidity vs 68% in Conventional Hospitalization. 11% of patients treated at home were diabetic. Thickening colonic wall was present in 100% of patients. 38% of patients treated at home had free fluid vs 42% treated in Hospital. All patients had a good clinical evolution. None of the patients treated at home was transferred to Hospital. Home treatment was associated with a cost reduction of 1368 euros per patient. CONCLUSIONS Treatment at home of elderly patients with uncomplicated diverticulitis is as safe and effective as treatment in Hospital, even if patient has comorbidity.
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92
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Lorente L, Cots F, Alonso S, Pascual M, Salvans S, Courtier R, Gil MJ, Grande L, Pera M. [Outpatient treatment of uncomplicated acute diverticulitis: Impact on healthcare costs]. Cir Esp 2013; 91:504-9. [PMID: 23764519 DOI: 10.1016/j.ciresp.2013.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 01/09/2013] [Accepted: 01/26/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. PATIENTS AND METHODS A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). RESULTS A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001). CONCLUSIONS Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.
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Affiliation(s)
- Leyre Lorente
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital del Mar d'Investigacions Me'diques (IMIM), Barcelona, España
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93
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Tan KK, Wong J, Sim R. Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients. Int J Colorectal Dis 2013; 28:849-854. [PMID: 23070046 DOI: 10.1007/s00384-012-1595-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Data highlighting the long-term outcome following an initial episode of right-sided colonic diverticulitis is lacking. This study aims to evaluate and follow up on all patients with right-sided colonic diverticulitis. METHODS A retrospective review of all patients who were discharged with a diagnosis of right-sided colonic diverticulitis from January 2003 to April 2008 was performed. RESULTS A total of 226 patients, with a median age of 49 (range, 16-93) years, were admitted for acute right-sided colonic diverticulitis. The majority of the patients (n = 198, 87.6 %) had mild diverticulitis (Hinchey Ia and Ib). Seventy-three (32.3 %) patients underwent emergency surgery. The indications of surgery were predominantly suspected appendicitis (n = 50, 22.1 %) and perforated diverticulitis (n = 16, 7.1 %). Right hemicolectomy was performed in 32 (43.8 %) patients, while appendectomy, with or without diverticulectomy, was performed in the rest (n = 41, 56.2 %). There were seven patients who underwent elective right hemicolectomy after their acute admissions.Over a median duration of 64 (12-95) months, there were only nine patients who were readmitted 12 times for recurrent diverticulitis at a median duration of 17 (1-48) months from the index admission. The freedom from failure (recurrent attacks or definitive surgery (right hemicolectomy)) at 60 months was 92.0 % (95 % Confidence interval 86.1 %-97.9 %). CONCLUSION Right-sided diverticulitis is commonly encountered in the Asian population and often gets misdiagnosed as acute appendicitis. If successfully managed conservatively, the long-term outcome is excellent.
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Affiliation(s)
- Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore.
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94
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Abbas MA, Cannom RR, Chiu VY, Burchette RJ, Radner GW, Haigh PI, Etzioni DA. Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment? Colorectal Dis 2013; 15:451-7. [PMID: 23061533 DOI: 10.1111/codi.12057] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/22/2012] [Indexed: 02/08/2023]
Abstract
AIM Current recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient. METHOD A retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤ 3 days and no readmission for diverticulitis within 30 days after discharge. RESULTS Of 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess < 3 cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient-level predictors, the model did not identify patients likely to need only minimal hospitalization. CONCLUSION Most patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.
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Affiliation(s)
- M A Abbas
- Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA
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95
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O’Connor ES, Smith MA, Heise CP. Outpatient diverticulitis: mild or myth? J Gastrointest Surg 2012; 16:1389-96. [PMID: 22411489 PMCID: PMC3638980 DOI: 10.1007/s11605-012-1861-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 02/26/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diverticulitis is considered common in the outpatient population, with mild variants of described diagnostic criteria: left lower quadrant pain, fever, and leukocytosis. Here, expected criteria utilization among outpatients with a possible diagnosis of diverticulitis is assessed. STUDY DESIGN Primary care acute clinic visits in 2008 for diverticulitis (ICD-9 562.11/562.13) or left lower quadrant pain (789.04) were identified among patients ≥ 40 years old. Encounters were reviewed through structured manual chart abstraction and evaluated for diagnostic accuracy compared to expected criteria. Analysis included inter-rater reliability (kappa tests) and descriptive frequencies by diagnosis code and diverticulitis rating (χ (2) tests). RESULTS A total of 376 acute visits were identified with codes for diverticulitis (n=97) or left lower quadrant pain (n=279). High inter-rater reliability was demonstrated for key clinical variables (kappa=0.84-1.0). Left lower quadrant pain was reported in >75% of patients, while temperature and white blood cell count data were frequently unavailable. Lack of these expected criteria resulted in low diagnostic accuracy ratings ("No/unlikely"-53.6% diverticulitis, 88.2% left lower quadrant pain, p<0.001). CONCLUSIONS This investigation raises concern for low accuracy in the outpatient diagnosis of diverticulitis due to inconsistent use of expected criteria, suggesting a smaller population with true diverticulitis than previously anticipated, or lack of criteria applicability in this setting.
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Affiliation(s)
- Erin S. O’Connor
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Maureen A. Smith
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Charles P. Heise
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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96
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Schlammes S, Peter MK, Candinas D, Egger B. Extended abstract: long-term outcome of elective surgery--symptoms, cicatricial hernia and ileostomy/colostomy rate. Dig Dis 2012; 30:118-21. [PMID: 22572698 DOI: 10.1159/000335917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Serge Schlammes
- Department of Surgery, HFR Fribourg, Cantonal Hospital, Fribourg, Switzerland
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97
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Sai VF, Velayos F, Neuhaus J, Westphalen AC. Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review. Radiology 2012; 263:383-90. [PMID: 22517956 PMCID: PMC3329267 DOI: 10.1148/radiol.12111869] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To estimate the prevalence of underlying adenocarcinoma of the colon in patients in whom acute diverticulitis was diagnosed at computed tomography (CT) and to compare that to the prevalence of colon cancer in the general population. MATERIALS AND METHODS A comprehensive literature review was performed to find articles in which patients with CT diagnosis of acute diverticulitis underwent surgery, colonoscopy, or barium enema study within 24 weeks. Patients meeting these criteria were included for analysis. A pooled prevalence of cancer was calculated on the basis of a random effects model and compared qualitatively with the prevalence of cancer in the general population. The 95% confidence intervals around the prevalence of cancer in the study populations were determined. RESULTS Ten articles met the inclusion criteria. Data from these articles included only 771 patients who underwent surgery, colonoscopy, or barium enema study within 24 weeks of diagnosis. Fourteen patients were found to have colon cancer, for a prevalence of 2.1% (95% confidence interval: 1.2%, 3.2%). This compares to a calculated estimated prevalence of 0.68% among U.S. adults older than 55 years. CONCLUSION There are limited data to support the recommendation to perform colonoscopy after a diagnosis of acute diverticulitis.
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Affiliation(s)
- Victor F Sai
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA.
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98
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Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment. Surg Endosc 2012; 26:2061-71. [PMID: 22274929 DOI: 10.1007/s00464-012-2157-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 12/20/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. METHODS The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. RESULTS There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). CONCLUSIONS Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.
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99
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Helwig U. Möglichkeiten und Grenzen der ambulanten Therapie der Divertikelkrankheit. VISZERALMEDIZIN 2012; 28:182-189. [DOI: 10.1159/000339393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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100
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Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis 2012; 14:e1-e11. [PMID: 21848896 DOI: 10.1111/j.1463-1318.2011.02766.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidence-based review. METHOD A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic significance were reviewed. Criteria for eligibility of the studies were diagnosis and classification, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors. RESULTS Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria. CONCLUSION The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis.
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Affiliation(s)
- S Biondo
- Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, IDIBELL (Bellvitge Biomedical Research Institute), Barcelona, Spain.
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