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Ambrosetti P. Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. Clin Exp Gastroenterol 2016; 9:249-57. [PMID: 27574459 PMCID: PMC4993273 DOI: 10.2147/ceg.s110428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Geneva, Switzerland
- Correspondence: Patrick Ambrosetti, Department of Surgery, Clinique Générale Beaulieu, Ch Beau-Soleil, 1205 Geneva, Switzerland, Tel +41 22 830 0520, Fax +41 22 830 2343, Email
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Hartwich J, Luks FI, Watson-Smith D, Kurkchubasche AG, Muratore CS, Wills HE, Tracy TF. Nonoperative treatment of acute appendicitis in children: A feasibility study. J Pediatr Surg 2016; 51:111-6. [PMID: 26547287 DOI: 10.1016/j.jpedsurg.2015.10.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 01/11/2023]
Abstract
PURPOSE Nonoperative treatment of acute appendicitis appears to be feasible in adults. It is unclear whether the same is true for children. METHODS Children 5-18 years with <48 h symptoms of acute appendicitis were offered nonoperative treatment: 2 doses of piperacillin IV, then ampicillin/clavulanate ×1 week. Treatment failure (worsening on therapy) and recurrence (after completion of therapy) were noted. Patients who declined enrollment were asked to participate as controls. Cost-utility analysis was performed using Pediatric Quality of Life Scale (PedsQL®) to calculate quality-adjusted life month (QALM) for study and control patients. RESULTS Twenty-four patients agreed to undergo nonoperative management, and 50 acted as controls. At a mean follow-up of 14 months, three of the 24 failed on therapy, and 2/21 returned with recurrent appendicitis at 43 and 52 days, respectively. Two patients elected to undergo an interval appendectomy despite absence of symptoms. Appendectomy-free rate at one year was therefore 71% (C.I. 50-87%). No patient developed perforation or other complications. Cost-utility analysis shows a 0.007-0.03 QALM increase and a $1359 savings from $4130 to $2771 per nonoperatively treated patient. CONCLUSION Despite occasional late recurrences, antibiotic-only treatment of early appendicitis in children is feasible, safe, cost-effective and is experienced more favorably by patients and parents.
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Affiliation(s)
- Joseph Hartwich
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
| | - Francois I Luks
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI.
| | - Debra Watson-Smith
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
| | - Arlet G Kurkchubasche
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
| | - Christopher S Muratore
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
| | - Hale E Wills
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
| | - Thomas F Tracy
- Division of Pediatric Surgery Hasbro Children's Hospital and Alpert Medical School of Brown University, Providence, RI
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Abstract
The surgical management of diverticulitis continues to evolve but recent literature has not qualified just how different current practice is compared with the previous era. This study aims to update the seminal paper by Rodkey and Welch regarding indications and operation types performed for diverticulitis by comparing their findings with present practice at a community based institution. The charts of 407 patients admitted with "diverticular disease" between 2005 and 2010 were identified. For each admission, patients' demographics, presentations and management were recorded. Direct comparisons were made with results from the study by Rodkey and Welch. Of the 407 admissions studied, the distribution was 335 emergency and 72 elective. Medical management alone treated 90% of emergency admissions, while 4% required additional radiologic intervention. Emergency surgery was necessary in only 6% of cases with Hartmann's procedure being the most common procedure. Recurrent diverticulitis was a prime indication for elective surgery with 96% of cases undergoing a 1-staged procedure. Compared with the previous era, the nonoperative approach to managing acute diverticulitis is now applied for the vast majority of admissions. Improved success in medically temporizing patients in the present era has allowed for a higher percentage of successful single-staged elective surgeries.
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104
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-626. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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105
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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106
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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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107
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El-Batrawy TM, Al Ashari M, Abu-Zidan FM. Perforated solitary diverticulitis of the transverse colon in a young woman. ANZ J Surg 2015; 87:948-949. [PMID: 25892611 DOI: 10.1111/ans.13123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mouied Al Ashari
- Department of Pathology, Tawam Hospital, Al-Ain, United Arab Emirates
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
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108
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109
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Abstract
BACKGROUND The optimal treatment of acute complicated diverticulitis is a matter of debate and has undergone significant changes. Currently, the main focus of surgical treatment concepts is on controlling the emergency situation triggered by acute complicated sigmoid diverticulitis through interventional and minimally invasive measures. METHODS This article presents the current data and recommendations on differentiated treatment of acute complicated sigmoid diverticulitis, which are also summarized in a decision tree. RESULTS In general, resection of the diverticular sigmoid is needed to treat acute complicated sigmoid diverticulitis, because without resection the recurrence rate is too high at 40%. Since the morbidity and mortality rates associated with emergency resection are extremely high, resulting in the creation of a stoma, efforts are made to control the acute situation through interventional and laparoscopic measures. Therefore, pericolic and pelvic abscesses (Hinchey stages I, II) are eliminated through percutaneous or laparoscopic drainage. Likewise, laparoscopic lavage and drainage are performed for purulent and feculent peritonitis (Hinchey stages III, IV). After elimination of the acute septic situation, interval elective sigmoid resection is conducted. If emergency resection cannot be avoided, it is performed, while taking account of the patient's overall condition, with primary anastomosis and a protective stoma or as discontinuity resection using Hartmann's procedure. CONCLUSION Thanks to the progress made in interventional and laparoscopic treatment, differentiated concepts are now used to treat acute complicated sigmoid diverticulitis.
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110
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Fung AKY, Ahmeidat H, McAteer D, Aly EH. Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention. Ann R Coll Surg Engl 2015; 97:208-14. [PMID: 26263806 PMCID: PMC4474014 DOI: 10.1308/003588414x14055925061315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2014] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The current surgical management of acute complicated diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. This has been made possible by the widespread availability of computed tomography (CT) to enable stratification of the disease severity of acute complicated diverticulitis. The aim of this study was to retrospectively validate a CT grading system for acute complicated diverticulitis in the prediction of the need for operative or percutaneous intervention. METHODS Hospital and radiology records were reviewed to identify patients with acute complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, blinded to the clinical outcomes of patients, assigned a score according to the CT grading system. RESULTS Three hundred and sixty-seven patients (34.6%) had CT performed for acute diverticulitis during the study period. Forty-four patients (12.0%) had acute complicated diverticulitis (abscess and/or free intraperitoneal air) confirmed on CT. There were 22 women (50%) and the overall median age was 59 years (range: 19-92 years). According to the CT findings, there was one case with grade 1, eighteen patients with grade 2, four with grade 3 and twenty-one with grade 4 diverticulitis. Three patients with grade 2, three patients with grade 3 and ten patients with grade 4 disease underwent acute radiological or surgical intervention. CONCLUSIONS The use of a CT grading system for acute complicated diverticulitis did not predict the need for acute radiological or operative intervention in this small study. Decision making guided by the patient's clinical condition still retains a primary role in the management of acute complicated diverticulitis.
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112
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Staging of acute diverticulitis based on clinical, radiologic, and physiologic parameters. J Trauma Acute Care Surg 2015; 78:543-51. [DOI: 10.1097/ta.0000000000000540] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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113
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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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Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis. Dis Colon Rectum 2014; 57:1397-405. [PMID: 25380006 DOI: 10.1097/dcr.0000000000000224] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. OBJECTIVE The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. DESIGN This is a population-based retrospective cohort study using administrative discharge data. SETTING This study was conducted in Ontario, Canada. PATIENTS All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). MAIN OUTCOME MEASURES Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. RESULTS There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001). LIMITATIONS There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data. CONCLUSIONS There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.
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115
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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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116
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Laparoscopic peritoneal lavage for Hinchey III diverticulitis: is it as effective as it is applicable? Dis Colon Rectum 2014; 57:1384-90. [PMID: 25380004 DOI: 10.1097/dcr.0000000000000252] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. OBJECTIVE The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. DESIGN This study was conducted as a retrospective analysis of prospectively collected data. SETTING This study was conducted at a single tertiary care institution. PATIENTS Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. MAIN OUTCOME MEASURES Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. RESULTS Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93). LIMITATIONS This was a single-institution retrospective study. CONCLUSIONS The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.
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Affiliation(s)
- Byung Chun Kim
- Department of Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Suarez Alecha J, Amoza Pais S, Batlle Marin X, Oronoz Martinez B, Balen Ribera E, Yarnoz Irazabal C. Safety of nonoperative management after acute diverticulitis. Ann Coloproctol 2014; 30:216-21. [PMID: 25360428 PMCID: PMC4213937 DOI: 10.3393/ac.2014.30.5.216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 07/30/2014] [Indexed: 01/01/2023] Open
Abstract
Purpose The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery. Methods We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode. Results Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated with elective surgery had a higher rate of stoma than patients treated non-operatively (7.2% vs. 1.4%; P = 0.028); this difference was not observed in the subgroup of patients with CAD (15.3% vs. 6.8%; P = 0.458). Conclusion After an episode of AD, nonoperative management is safe because fewer than 5% of patients will need an emergent procedure in a subsequent attack of AD. A first episode of CAD is the only risk factor for emergency surgery in patients managed conservatively.
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Affiliation(s)
- Javier Suarez Alecha
- Departament of Surgery, Unit of Coloproctology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Sonia Amoza Pais
- Departament of Surgery, Unit of Coloproctology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Xavi Batlle Marin
- Departament of Surgery, Unit of Coloproctology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Begoña Oronoz Martinez
- Departament of Surgery, Unit of Coloproctology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Enrique Balen Ribera
- Departament of Surgery, Unit of Coloproctology, Complejo Hospitalario de Navarra, Pamplona, Spain
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Abstract
Intra-abdominal infections are multifactorial, but all require prompt identification, diagnosis, and treatment. Resuscitation, early antibiotic administration, and source control are crucial. Antibiotic administration should initially be broad spectrum and target the most likely pathogens. When cultures are available, antibiotics should be narrowed and limited in duration. The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition. Patient-specific factors (advanced age and chronic medical conditions) as well as disease-specific factors (health care-associated infections and inability to obtain source control) combine to affect patient morbidity and mortality.
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Affiliation(s)
- Gina R Shirah
- Division of Trauma & Critical Care Surgery, Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
| | - Patrick J O'Neill
- Trauma Department, West Valley Hospital, 13677 W McDowell Road, Goodyear, AZ 85395, USA.
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Bridoux V, Antor M, Schwarz L, Cahais J, Khalil H, Michot F, Tuech JJ. Elective operation after acute complicated diverticulitis: Is it still mandatory? World J Gastroenterol 2014; 20:8166-8172. [PMID: 25009389 PMCID: PMC4081688 DOI: 10.3748/wjg.v20.i25.8166] [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: 10/16/2013] [Revised: 01/04/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD).
METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed.
RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain.
CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.
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Fleshman JW, Roberts WC. James Walter Fleshman Jr., MD: a conversation with the editor. Proc (Bayl Univ Med Cent) 2014; 27:263-75. [PMID: 24982584 DOI: 10.1080/08998280.2014.11929133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- James W Fleshman
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
| | - William C Roberts
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
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Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients. Dis Colon Rectum 2014; 57:875-81. [PMID: 24901689 DOI: 10.1097/dcr.0000000000000083] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal treatment for diverticulitis with extraluminal air is controversial. OBJECTIVE The purpose of this research was to evaluate the safety and effectiveness of nonoperative treatment of acute diverticulitis with extraluminal air. DESIGN This was a retrospective cohort. SETTINGS The study was conducted at an academic teaching hospital functioning as both a tertiary and secondary care referral center. PATIENTS All of the patients with CT-diagnosed acute perforated diverticulitis with extraluminal air from 2006 through 2010 were included in this study. INTERVENTIONS Nonoperative treatment composed of intravenous antibiotics, bowel rest, and percutaneous drainage were the included interventions. MAIN OUTCOME MEASURES The need for operative management and mortality were measured. RESULTS A total of 132 patients underwent nonoperative treatment, whereas 48 patients were primarily operated on. Patients treated nonoperatively were divided into 3 groups on the basis of identified factors that independently predicted risk for failure: 1) patients with pericolic air (n = 82) without abscess had a 99% success rate with 0% mortality. 2) Patients with distant intraperitoneal air (n = 29) had a 62% success ratewith 0% mortality. Abundant distant intraperitoneal air and fluid in the fossa Douglas were identified as risk factors for failure. Patients without these risk factors had an 86% success rate with nonoperative management. 3) Patients with distant retroperitoneal air (n = 14) had a 43% success rate with 7% mortality. LIMITATIONS Comparison of nonoperative versus operative treatment cannot be made because of the study's retrospective nature. CONCLUSIONS Nonoperative treatment of acute diverticulitis with extraluminal air is safe and effective in patients with a small amount of distant intraperitoneal air or pericolic air without clinical signs of peritonitis.
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Unlü C, Beenen LFM, Fauquenot JMB, Jensch S, Bemelman WA, Dijkgraaf MGW, Vrouenraets BC, Boermeester MA, Stoker J. Inter-observer reliability of computed tomographic classifications of diverticulitis. Colorectal Dis 2014; 16:O212-9. [PMID: 24344689 DOI: 10.1111/codi.12533] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 11/18/2013] [Indexed: 12/12/2022]
Abstract
AIM The wide use of computed tomography (CT) for diverticulitis has initiated new classifications, but their reliability has not been studied. The aim of the study was to assess the inter-observer agreement of radiologists on the classifications of diverticulitis. METHOD A set of 100 CT examinations of patients with an episode of diverticulitis was used to assess inter-observer agreement. Cases were derived from two prospective trials and a retrospective cohort to comprise an evenly distributed case mix of patients. The reference standard was the modified Hinchey classification based on all available information. Three blinded radiologists independently read all CT examinations. We calculated the proportion of agreement and kappa values for the Hinchey and Ambrosetti classifications. For the Dharmarajan classification only inter-observer agreement was calculated. RESULTS The agreement with the reference standard was substantial for both the modified Hinchey and the Ambrosetti classifications (P = 0.68 and P = 0.76). Overall inter-observer agreement for the modified Hinchey classification was substantial (median kappa 0.72), for the Ambrosetti classification almost perfect (median kappa 0.83) and for the Dharmarajan classification substantial (median kappa 0.76). CONCLUSION The Ambrosetti classification is more reproducible than the modified Hinchey and Dharmarajan classifications. The Ambrosetti and modified Hinchey classifications have a substantial agreement with the reference standard and therefore produce a reliable classification. The Dhamarajan is applicable only in complicated diverticulitis and is an important complementary classification to the other more general classifications of diverticulitis.
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Affiliation(s)
- C Unlü
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients. J Trauma Acute Care Surg 2014; 76:704-9. [PMID: 24553537 DOI: 10.1097/ta.0000000000000128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The epidemic increase in the incidence of diabetes mellitus (DM) worldwide represents a potential source of surgical morbidity. The impact of DM on the need for surgical management and its effect on surgical outcomes for colonic diverticulitis have not been well defined. METHODS We investigated all DM versus non-DM patients admitted with a diagnosis of acute diverticulitis between January 1, 2003, and December 31, 2011, to a large urban safety net hospital. An administrative database search for patients with diverticulitis was divided into two groups: those with and without DM. They were retrospectively analyzed for severity of diverticulitis (Hinchey and Ambrosetti scores), mortality, length of hospital stay, need for operation, postoperative complications, and readmission rates. RESULTS There were 1,019 admissions with acute diverticulitis, 164 (16.1%) of which had DM. DM versus non-DM patients presented with a higher Hinchey score of 3 or 4 (12.2% vs. 9.2%, p < 0.001), a more severe computed tomographic Ambrosetti score (43.9% vs. 31.7%, p < 0.001), older age, and significantly more comorbid conditions. There was no significant difference in the failure of nonoperative management (2.2% DM vs. 2.5% non-DM, p = 1.000), readmission, or death rates. Operated DM patients had a higher incidence of in-hospital infectious complications (28.7% vs. 8.2%, p < 0.001) and a higher incidence of acute renal failure (5.5% vs. 0.7%, p < 0.001). CONCLUSION Although diabetic patients with colonic diverticulitis present at a more advanced level (as measured by Hinchey and Ambrosetti scores), the nonoperative success rate is similar to non-DM patients. Surgical management in DM patients is associated with a higher incidence of infectious complications and acute kidney injury. However, DM did not appear to increase operative mortality in surgically managed patients. These data suggest that greater attention should be placed on steps to reduce the negative impact of DM on both immune response and renal function in patients requiring surgery of colonic diverticulitis. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Abstract
BACKGROUND Data on percutaneous drainage followed by observation for diverticular abscess is scant. OBJECTIVE The aim of this study is to assess outcomes of percutaneous drainage alone in the management of peridiverticular abscess. DESIGN This is a retrospective study from a prospectively collected database. SETTING This study was conducted in a high-volume, specialized colorectal surgery unit. PATIENTS All patients with a diverticular abscess of at least 3 cm in diameter, treated between 2001 and 2012, who had prohibitive comorbidities or refused surgery after percutaneous drainage were included. MAIN OUTCOME MEASURES The primary outcome measured was the treatment of diverticular abscess with percutaneous drainage alone. RESULTS A total of 18 patients (11 surgery refusal, 7 comorbidity) were followed up until death, surgery for recurrent diverticulitis, or for a median of 90 (17-139) months. The median abscess size was 5 (3.8-10) cm, and the location was pelvic in 8 cases and intra-abdominal in 10. The mean duration of drainage was 20 ± 1.3 days, with the exception of 2 patients who only had aspiration of the abscess because of technical difficulty in drain placement. Three patients died of preexisting comorbidities between 2 and 8 months after percutaneous drainage. Seven of the surviving patients (7/15) experienced recurrent diverticulitis; 3 of these patients underwent surgery between 7 months and 7 years after the index percutaneous drainage. Of the remaining 4 cases of recurrence, one abscess was treated with repeat percutaneous drainage alone and 3 patients had uncomplicated diverticulitis treated with antibiotics. There were no significant associations between long-term failure of percutaneous drainage and the location of the abscess (p = 0.54) or previous episodes of diverticulitis (p = 0.9). LIMITATIONS This study was limited because of its retrospective nature, its nonrandomized design, and its small sample size. CONCLUSIONS Percutaneous drainage alone was successful in avoiding surgery in the majority of this selected patient population with sigmoid diverticular abscess. Future studies should assess the appropriate indications for a more liberal use of percutaneous drainage not followed by elective surgery.
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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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Durán-Ramos O. [Paradigm shift in diverticulitis]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78 Suppl 1:83-5. [PMID: 24041069 DOI: 10.1016/j.rgmx.2013.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 11/28/2022]
Affiliation(s)
- O Durán-Ramos
- Coloproctólogo del Hospital San Javier de la Ciudad de Guadalajara, Jal.
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Swank H, Bemelman W. Authors' reply: Early experience with laparoscopic lavage for perforated diverticulitis (Br J Surg 2013; 100: 704-710). Br J Surg 2013; 100:1254. [PMID: 23842839 DOI: 10.1002/bjs.9217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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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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Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air. J Trauma Acute Care Surg 2013; 74:1376. [DOI: 10.1097/ta.0b013e31828c31ab] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Persistent perforation in non-faeculant diverticular peritonitis--incidence and clinical significance. J Gastrointest Surg 2013; 17:369-73. [PMID: 23011202 DOI: 10.1007/s11605-012-2025-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 08/27/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-resectional strategies (NRS) have improved outcomes for a sub-group of patients with perforated diverticulitis. NRS are applicable to patients with non-faeculant peritonitis (Hinchey II and III). Success is dependent on the initial perforation sealing, which Hinchey estimated occurred 'most of the time'. An exact percentage remains ill-defined. OBJECTIVE We aimed to define the percentage and clinical significance of a persistent perforation in non-faeculant diverticular peritonitis. DESIGN A retrospective review was conducted of all patients admitted with a diagnosis of perforated diverticulitis between January 1999 and July 2010. Patients undergoing an emergency operation were analysed according to Hinchey and physiological and operative severity scores and compared with histological findings. RESULTS One hundred fifteen patients were identified. Fifty-three patients underwent a 'resectional' procedure. At surgery, 15 patients had faeculent peritonitis, 27 patients had purulent peritonitis and 11 patients had a contained abscess. Of the patients with non-faeculant peritonitis, 2/9 (22.2 %) Hinchey II and 10/27 (37.1 %) Hinchey III patients had persistent perforation on review of histology. Persistent perforation was associated with a significant increase in morbidity, length of stay, physiological and operative severity score (p = 0.015, 0.011, 0.049 and 0.002, respectively). CONCLUSION A proportion of patients with non-faeculant peritonitis have a persistent perforation which is associated with a poorer outcome and is likely to result in failure of a non-resectional management strategy. Updated classification systems and tailored peri-operative investigations are required to identify this sub-group of patients and improve patient outcomes.
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Uematsu D, Akiyama G, Magishi A, Sano T, Niitsu H, Narita M, Komatsu H. Laparoscopic Hartmann's procedure for fecal peritonitis resulting from perforation of the left-sided colon in elderly and severely ill patients. Tech Coloproctol 2012; 16:243-6. [PMID: 22527923 DOI: 10.1007/s10151-012-0828-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 03/12/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traditional treatment for fecal peritonitis resulting from perforation of the left-sided colon has been performed using Hartmann's procedure to reduce the high mortality caused by anastomotic leakage. However, the morbidity rates associated with abdominal incision (due in great part to wound infection, and dehiscence of abdominal fascia) are high. Therefore, we propose using laparoscopic Hartmann's procedure with abdominal incisions only for the port site to reduce the high morbidity associated with the laparoscopic procedure as compared to open surgery. METHODS Between April 2008 and July 2011, we treated 16 consecutive patients (median age, 83 years) with fecal peritonitis resulting from perforations in the left-sided colon due to various causes. The American Society of Anesthesiologists score of each patient was either IV or V. Patients underwent a four-port laparoscopic Hartmann's procedure. Specimens were extracted through the stoma site. Irrigation of the abdominal cavity with more than 10 L of saline was performed in every case, as was insertion of three 10-mm silicon drains via the port site into the left- and right subphrenic spaces or the pouch of Douglas. RESULTS The median total surgical time was 166 min (range, 123-250 min). There were no intraoperative complications, and there was no need to convert to open surgery. Fourteen patients survived. There was no wound infection or dehiscence of abdominal fascia. Successful laparoscopic reversals of the laparoscopic Hartmann's procedure were performed in all 14 survivors. CONCLUSIONS This laparoscopic Hartmann's procedure is a promising surgical strategy for treating fecal peritonitis arising from perforation of the left-sided colon.
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Affiliation(s)
- D Uematsu
- Department of Colorectal Surgery, Saku Central Hospital, 197 Usuda, Saku-City, Nagano, 384-0301, Japan.
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Aly EH. Colorectal surgery: current practice & future developments. Int J Surg 2012; 10:182-6. [PMID: 22406541 DOI: 10.1016/j.ijsu.2012.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 02/23/2012] [Indexed: 12/20/2022]
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Sigmoidectomy syndrome? Patients' perspectives on the functional outcomes following surgery for diverticulitis. Dis Colon Rectum 2012; 55:10-7. [PMID: 22156862 DOI: 10.1097/dcr.0b013e31823907a9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bowel function following surgery for diverticulitis has not previously been systematically described. OBJECTIVE This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis. DESIGN This study is a retrospective analysis. SETTING This study was conducted at a large, academic medical center. PATIENTS Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument. MAIN OUTCOME MEASURES Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function. RESULTS Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥ 24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥ 4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥ 4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05). LIMITATIONS This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms. CONCLUSION One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.
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