The efficacy of nonoperative management of acute complicated diverticulitis

Surveillance and follow-up in acute diverticulitis with pericolic free gas (ADiFas II): an age-specific analysis

The objective of this study was to examine the differences in clinical presentation and complications during the first year of follow-up in patients who experienced an episode of acute diverticulitis (AD) with pericolic free gas, comparing outcomes across different age groups. A prospective subanalysis was conducted on a cohort from the ADiFAS study, which originally included 1099 patients. After excluding 289 patients who did not meet the inclusion criteria, 810 patients remained for analysis. From this cohort, 330 patients with AD and pericolic free gas were selected using propensity score matching and divided into two age groups: < 65 years and ≥ 65 years. The groups were matched based on sex, BMI, diabetes mellitus (DM), cardiovascular disease, previous episodes of AD, and the presence of free fluid on CT scan. Data were assessed for Hinchey classification, surgical procedures, complications, and the frequency of surveillance through colonoscopy and CT scans. The study found a significantly higher rate of surgery in the older group during the index episode (17% vs. 4.2%, p = 0.000). A higher proportion of patients in the older group were misclassified as Hinchey II (18.2% vs. 6.4%, p = 0.007) and Hinchey III (2.3% vs. 0.7%, p = 0.304). All patients classified as Hinchey III (1 in the younger group and 3 in the older group) underwent emergency surgery. In the younger group, 2 out of 8 emergency surgeries were for patients classified as Hinchey II, compared to 11 out of 28 in the older group. Only 58% of patients underwent any form of imaging or endoscopic surveillance during the first year of follow-up. Among those, complications such as abscess, fistula, or stenosis were observed in 17% of patients, occurring more frequently in the older group (16.9% vs. 5.7%, p = 0.089). Nearly 50% of these patients required surgery, with 6 cases in the younger group and 9 in the older group. Emergency surgeries were more common in the older group (2.4% vs. 0.6%, p = 0.186), as was elective surgery (10.3% vs. 7.9%, p = 0.283). A conservative approach, combined with meticulous monitoring through regular follow-ups and imaging, can be effectively employed in managing patients with acute diverticulitis and pericolic free gas. However, our findings highlight the critical need for rigorous surveillance, especially in older patients, due to the higher prevalence of long-term complications.

30-Day Readmissions and the Need for Emergency Surgery Following Non-Operative Management of Perforated Diverticulitis

Background: Limited data are available on the evaluation and outcomes of patients with perforated diverticulitis who were treated without surgery. Aims: This retrospective review was aimed at investigating the 30-day non-elective re-admission rates for patients hospitalized with perforated diverticular disease who were treated without surgery, rates of patients requiring surgery on re-admission, and the independent predictors of re-admission. Methods: A total of 143,546 patients from the National Readmission Database, between 2016 and 2020, who were admitted with perforated diverticulitis and treated non-operatively were reviewed. Re-admitted patients were compared with those not re-admitted. Comparisons for continuous and categoric variables were made using the student t-test and chi-squared test, respectively. A logistic regression model was used to determine independent factors associated with re-admission. All analyses were done with SAS 9.4; p values <0.05 identified significance. Results: Among patients with perforated diverticulitis who were treated non-operatively, 17,868 (12.4%) were re-admitted within 30 days and 4,924 (27.6%) of patients re-admitted required surgical intervention. The greatest independent predictors of re-admission include patient insurance status, index length of stay, undergoing a drainage procedure, and patient disposition. Comorbidities predicting re-admission include renal failure, chronic pulmonary disease, diabetes mellitus, fluid and electrolyte disorders, and hypertension. Hospital total charges were greater at the index admission for patients requiring re-admission. Conclusion: Non-operative management of perforated diverticulitis is safe for many patients, but the risks for re-admission and subsequent need for emergency surgery require special consideration.

Current Management of Diverticulitis

Over the last few decades, our understanding of the pathophysiology and natural history of sigmoid diverticulitis has greatly improved. This knowledge has challenged many of the traditional principles in the management for diverticulitis, such as routine antibiotic administration in all cases, number-based recommendations for elective surgery, and the necessity for an end colostomy in emergency surgery. This review will cover the breadth of management for sigmoid diverticulitis, covering both uncomplicated and complicated disease as well as elective and emergent disease presentations. New and emerging concepts in management will be highlighted with a particular focus on level-1 data, when available.

Nonoperative management of acute complicated diverticulitis with pericolic and/or distant extraluminal air: A systematic review

INTRODUCTION

Colonic Diverticular Disease (CDD) is a multifactorial inflammatory disease. Acute diverticulitis (AD), with extraluminal free air (both pericolic and distant), represents about 15% of radiological scenarios and remains a therapeutic challenge for surgeons. Currently, the WSES guidelines suggest trying a conservative strategy both in the presence of pericolic and distant free extraluminal air, even if both have respectively weak recommendation based on low/very low-quality evidence.

METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. PubMed/MEDLINE, Scopus, Web of Science, and Embase databases were used to identify articles of interest.

RESULTS

A total of 2380 patients with AD and extraluminal free air (both pericolic and distant) who underwent nonoperative management (NOM) were analyzed. Of the 2380 patients, 2095(88%) were successfully treated with NOM, while 285 (12%) patients failed. A total of 1574 (93.1%) patients with pericolic extraluminal free air had a successful NOM with 6.9% (117) failure rates, while 135 (71.1%) patients with distant extraluminal free air had a successful NOM with 28.9% (55) failure rates. Regarding distant recurrence, we recorded a rate of 18.3% (261/1430), while a rate of 11.3% (167/1472) was recorded for patients undergoing elective surgery.

CONCLUSION

NOM for patients with AD and extraluminal free air (both pericolic and distant) seems to be feasible and safe despite a higher failure rate in the distant subgroup, which remains the most challenging clinical scenario to deal with through conservative treatment.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Classification of Diverticular Disease (CDD) - assessment of the intra- and interobserver agreement in abdominal CT scans

PURPOSE

Along with ultrasound, computed tomography (CT) is one of the imaging modalities of choice in patients with suspected diverticular disease (DD). Recently, a newer Classification of Diverticular Disease (CDD) has been proposed. However, its reliability in daily radiological practice has never been proven. Therefore, our aim was to evaluate the intra- and interobserver agreement of the CDD in abdominal CT scans.

METHODS

In this retrospective study, 481 CT scans of patients with suspected DD were included. Two readers (one board-certified radiologist with 6 years of experience, one 3 rd year radiology resident) individually evaluated all CTs in two reading sessions using the CDD. A composite endpoint of a prior consensus reading, follow-up, and intraoperative findings served as the reference. Intra- and interobserver agreement were calculated using Cohen-k statistic.

RESULTS

DD was present in 317 cases (66 %), mostly classified as CDD stage 0, 1b, and 2a (28 %, 30 %, und 14 %). Intraobserver agreement was almost perfect for both readers (kappa 0.93 and 0.88). Interobserver agreement was high and improved from substantial (kappa 0.77) in the first reading session to almost perfect (kappa 0.84) in the second reading session. The interobserver agreement was best for CDD types 0 (diverticulosis) and 2c (free perforated diverticulitis) (mean kappa 0.83 and 0.86) and poorest for CDD types 1a (diverticulitis without phlegmon) and 2b (covered diverticulitis with macroabscess) (mean kappa 0.17 and 0.38). Intra- and interobserver agreement of acute uncomplicated (CDD type 1) and acute complicated diverticulitis (CDD type 2) were substantial to almost perfect (mean kappa 0.63-0.86). Agreement with the reference was almost perfect for both observers (mean kappa 0.86 and 0.82). Administration of rectal contrast did not significantly improve the diagnosis.

CONCLUSION

The CDD is a classification based on relatively clear imaging characteristics, which can be readily applied by radiologists with different expertise. In our study, the CDD had a high intra- and interobserver agreement, enabling a reliable therapy-related categorization of DD.

KEY POINTS

· The Classification of Diverticular Disease (CDD) is an easy-to-use classification for diverticular disease based on relatively clear image features.. · The CDD can be applied equally by radiologists with different levels of experience in the clinical routine.. · The high intra- and interobserver agreement indicates high reliability in the therapy-relevant classification of diverticulitis on CT..

CITATION FORMAT

· Schmidbauer M, Levers A, Wacker FK et al. Classification of Diverticular Disease (CDD) - assessment of the intra- and interobserver agreement in abdominal CT scans. Fortschr Röntgenstr 2024; 196: 591 - 599.

Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study

BACKGROUND

Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure.

METHODS

A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission.

RESULTS

Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002).

CONCLUSIONS

Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

Short- and long-term outcomes of acute diverticulitis in patients with transplanted kidneys

AIM

The safety of nonoperative treatment for patients with transplanted kidneys who develop acute diverticulitis is unclear. Our primary aim was to examine the long-term sequelae of nonoperative management in this group.

METHOD

We performed a population-based retrospective cohort study using linked administrative databases housed at ICES in Ontario, Canada. We included adult (≥18 years) patients admitted with acute diverticulitis between April 2002 and December 2019. Patients with a functioning kidney transplant were compared with those without a transplant. The primary outcome was failure of conservative management (operation, drainage procedure or death due to acute diverticulitis) beyond 30 days. The cumulative incidence function and a Fine-Grey subdistribution hazard model were used to evaluate this outcome accounting for competing risks.

RESULTS

We examined 165 patients with transplanted kidneys and 74 095 without. Patients with transplanted kidneys were managed conservatively 81% of the time at the index event versus 86% in nontransplant patients. Short-term outcomes were comparable, but cumulative failure of conservative management at 5 years occurred in 5.6% (95% CI 2.3%-11.1%) of patients with transplanted kidneys versus 2.1% (95% CI 2.0%-2.3%) in those without. Readmission for acute diverticulitis was also higher in transplanted patients at 5 years at 16.7% (95% CI 10.1%-24.7%) versus 11.6% (95% CI 11.3%-11.9%). Adjusted analyses showed increased failure of conservative management [subdistribution hazard ratio (sHR) 3.24, 95% CI 1.69-6.22] and readmissions (sHR 1.55, 95% CI 1.02-2.36) for patients with transplanted kidneys.

CONCLUSION

Most patients with transplanted kidneys are managed conservatively for acute diverticulitis. Although long-term readmission and failure of conservative management is higher for this group than the nontransplant population, serious outcomes are infrequent, substantiating the safety of this approach.

Acute Colonic Diverticulitis

Acute colonic diverticulitis is a gastrointestinal condition that is frequently encountered by primary care and emergency department practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It is often diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, the presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.

Risk Factors for the Failure of Non-operative Management Among Patients Admitted for Colonic Diverticulitis

BACKGROUND

Diverticulitis is one of the most diagnosed gastrointestinal diseases in the country, and its incidence has risen over time, especially among younger populations, with increasing attempts at non-operative management. We elected to look at acute diverticular disease from the lens of a failure analysis, where we could estimate the hazard of requiring operative intervention based upon several clinical factors.

MATERIALS AND METHODS

The National Inpatient Sample (NIS) was queried between 2010 and 2015 for unplanned admissions among adults with a primary diagnosis of diverticulitis. We used a proportional hazards regression to estimate the hazard of failed non-operative management from multiple clinical covariates, measured as the number of inpatient days from admission until colonic resection. We also evaluated patients who received percutaneous drainage, to investigate whether this was associated with decreasing the failure rate of non-operative management.

RESULTS

A total of 830,993 discharges over the study period, of whom 83,628 (10.1%) underwent operative resection during the hospitalization, and 35,796 (4.3%) patients underwent percutaneous drainage. Half of all operations occurred by hospital day 1. Among patients treated with percutaneous drainage, 11% went on to require operative intervention. The presence of a peritoneal abscess (HR 3.20, P < .01) and sepsis (HR 4.16, P < .01) were the strongest predictors of failing non-operative management. Among the subset of patients with percutaneous drains, the mean time from admission to drain placement was 2.3 days.

CONCLUSION

Overall 10.1% of unplanned admissions for diverticulitis result in inpatient operative resection, most of which occurred on the day of admission. Percutaneous drainage was associated with an 11% operative rate.

Management of acute diverticulitis with pericolic free gas (ADIFAS): an international multicenter observational study

BACKGROUND

There are no specific recommendations regarding the optimal management of this group of patients. The World Society of Emergency Surgery suggested a nonoperative strategy with antibiotic therapy, but this was a weak recommendation. This study aims to identify the optimal management of patients with acute diverticulitis (AD) presenting with pericolic free air with or without pericolic fluid.

METHODS

A multicenter, prospective, international study of patients diagnosed with AD and pericolic-free air with or without pericolic free fluid at a computed tomography (CT) scan between May 2020 and June 2021 was included. Patients were excluded if they had intra-abdominal distant free air, an abscess, generalized peritonitis, or less than a 1-year follow-up. The primary outcome was the rate of failure of nonoperative management within the index admission. Secondary outcomes included the rate of failure of nonoperative management within the first year and risk factors for failure.

RESULTS

A total of 810 patients were recruited across 69 European and South American centers; 744 patients (92%) were treated nonoperatively, and 66 (8%) underwent immediate surgery. Baseline characteristics were similar between groups. Hinchey II-IV on diagnostic imaging was the only independent risk factor for surgical intervention during index admission (odds ratios: 12.5, 95% CI: 2.4-64, P =0.003). Among patients treated nonoperatively, at index admission, 697 (94%) patients were discharged without any complications, 35 (4.7%) required emergency surgery, and 12 (1.6%) percutaneous drainage. Free pericolic fluid on CT scan was associated with a higher risk of failure of nonoperative management (odds ratios: 4.9, 95% CI: 1.2-19.9, P =0.023), with 88% of success compared to 96% without free fluid ( P <0.001). The rate of treatment failure with nonoperative management during the first year of follow-up was 16.5%.

CONCLUSION

Patients with AD presenting with pericolic free gas can be successfully managed nonoperatively in the vast majority of cases. Patients with both free pericolic gas and free pericolic fluid on a CT scan are at a higher risk of failing nonoperative management and require closer observation.

Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study

AIM

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients.

METHOD

This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management.

RESULTS

Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p = 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79-16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p = 0.84) and failure of nonoperative management (7% vs. 9%, p = 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy.

CONCLUSION

Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.

Platelet to lymphocyte ratio is a risk factor for failure of non-operative treatment of colonic diverticulitis

Non-operative treatment is the mainstay of colonic diverticulitis, but some patients require surgery due to non-operative treatment failure. This study aims to identify risk factors for the failure of non-operative treatment of colonic diverticulitis. From January 2011 to December 2020, we retrospectively reviewed 2362 patients with non-operative treatment for first-attack acute diverticulitis. Patients were categorized into non-operative treatment success or failure groups. Clinical characteristics and serum inflammatory markers were analyzed by multivariable logistic regression to determine risk factors for non-operative treatment failure of colonic diverticulitis. Overall, 2.2% (n = 50) of patients underwent delayed surgery within 30 days (median 4.0 [3.0; 8.0]) due to non-operative treatment failure. Multivariable logistic regression identified that platelet to lymphocyte ratio (odds ratio [OR], 4.2; 95% confidence interval [CI], 0.05-0.13; p < 0.001), diabetes mellitus (OR, 2.2; 95% CI, 0.01-0.09; p = 0.025), left-sided colonic diverticulitis (OR, 4.1; 95% CI, 0.04-0.13; p < 0.001), and modified Hinchey classification (OR, 6.2; 95% CI, 0.09-0.17; p < 0.001) were risk factors for non-operative treatment failure. Platelet to lymphocyte ratio (PLR) is a potential risk factor for the non-operative treatment failure of acute first-attack colonic diverticulitis. Therefore, patients with higher PLR during non-operative treatment should be monitored with special caution.

Complicated Diverticulitis: Age Distribution, Management and Burden on Health Care

INTRODUCTION

Acute diverticulitis represents a common surgical condition and one of the leading gastrointestinal causes of hospital admissions in Western societies. The aim of the study is to examine the distribution, management and cost to healthcare of complicated diverticulitis and compare those to uncomplicated diverticulitis.

METHODS

The case-control study was performed for patients with acute diverticulitis in Lyell McEwin Hospital in Adelaide, South Australia. Data were collected for patients presented from January 2015 to December 2017. Consecutive patients with acute diverticulitis confirmed by computed tomography were included in the study. Patients recruited for the study were divided into two groups. Patients presenting with Hinchey Ia diverticulitis were classified as 'uncomplicated diverticulitis'. Patients who presented with Hinchey Ib, II, III or IV diverticulitis were classified as 'complicated diverticulitis'. The Hinchey classification was based on the radiological reports of CT scans.

RESULTS

From 2015-2017, 116 cases were screened for the study, 10 of which were excluded due to not having CT diagnosis. A total of 106 consecutive cases of acute diverticulitis were recruited for the study. Forty-four cases had complicated diverticulitis. Sixty-two cases with uncomplicated diverticulitis were allocated as a control group. The distribution of cases spanned through all age groups. There were nine cases (20.9%) in the 30-39 age group in the complicated diverticulitis compared to eight cases (12.9%) in the uncomplicated group with odds ratio 1.7 (0.61-4.92). The mean length of stay of the complicated diverticulitis group was 7.74 days compared to 3.93 days of the uncomplicated group with a p value of 0.000235. Nine (20%) cases of the 44 complicated diverticulitis cases were managed operatively, while 35 (80%) of the complicated diverticulitis group and all of the uncomplicated (control) group were managed conservatively. Localized perforations were 24 cases (54.5%) of the complicated diverticulitis group and collections were 18 cases (40.8%). Those cases collectively represented the majority of the complicated group.

CONCLUSION

Complicated diverticulitis increases the length of stay significantly in acute diverticulitis cases that are requiring hospital admission despite conservative management in 80% of the cases. Younger age groups represent a significant percentage of both complicated and uncomplicated diverticulitis. In the study population, the percentage of the younger age group was higher in complicated diverticulitis compared to uncomplicated diverticulitis, although this increased risk did not reach statistical significance. This will need to be further investigated in future studies.

German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

Operative rates in acute diverticulitis with concurrent small bowel obstruction

Background

The prevalence of diverticulitis has steadily increased during the past century. One possible complication of large bowel diverticulitis (LBD) is the concurrent development of a small bowel obstruction (SBO). The literature regarding these joint diagnoses is primarily limited to small case series from the 1950s. Consequently, no official recommendations or recent literature exists to guide decision making.

Methods

This is a retrospective case–control study with 5:1 matching by demographics, comorbidities, and Hinchey classification of patients presenting with concomitant LBD and SBO and patients with LBD alone. The primary outcome assessed was the need for same admission surgical intervention.

Results

Patients with concurrent LBD and SBO were more likely to require surgical intervention (OR 4.2, p<0.001) and more likely to receive an open operation than patients with only LBD (p<0.001). The length of stay (LOS) was longer for LBD with SBO (mean LOS +3.2 days, p=0.003).

Discussion

Patients with concurrent LBD and SBO are more likely to fail non-operative management. Given this, along with their longer LOS and higher rate of open surgery, earlier surgical intervention may improve outcomes and reduce hospital LOS.

Level of evidence

4.

Value of computed tomography scores in complicated acute diverticulitis

BACKGROUND

Diverticular disease remains one of the most common conditions in the western world. Up to 25% of patients with diverticular disease require hospitalization, 15-30% of those of which require surgical intervention. CT scoring systems have been proposed as means to drive assessment and stratify patients necessitating hospital intervention. To assess and correlate CT scoring systems with clinical and surgical outcomes.

METHODS

Retrospective cohort analysis at a single institution. Single institutional assessment with patients presenting to emergency with a CT diagnosed episode of acute diverticulitis. One hundred and eighty-nine patients were included in the study, 61% of which were male. Patient demographics, comorbidities, medications, biochemistry and inflammatory markers, type of complication following acute diverticulitis, operative/procedural intervention, hospital outcome and mortality were measured. CT scoring systems assessed included modified Hinchey, modified Neff, World Society of Emergency Surgery (WSES) and modified Siewert scoring systems.

RESULTS

Majority of patients had left-sided diverticulitis (91%) with localized air (88%) and pericolic abscess (49%) the most common radiological findings. 28% of patients required radiological and/or surgical management with 12% requiring intensive care unit (ICU) admission. There was a general trend for surgical/radiological intervention as the scores increased in severity. The four scoring systems were found to be statistically significant predictors of any intervention and of ICU admission with minimal statistical differences across the different scoring systems.

CONCLUSION

Radiological CT scores for complicated diverticulitis are at best, moderate predictors of clinical and surgical outcomes and may serve to guide management with minimal statistical differences across different scores.

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O₂ therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

How to strengthen the management of acute diverticulitis: the utility of the WSES classification-a prospective single-center observational study

PURPOSE

This study aimed to validate the World Society for Emergent Surgery (WSES) scale for the management of acute left-sided colonic diverticulitis (ALCD).

METHODS

An observational study based on a prospective database of patients with ultrasound (US) and computerized tomography (CT) confirmed ALCD was conducted at our center from April 2018 to May 2019. The primary outcome was the success rate of outpatient management. Secondary outcomes were the association between different WSES stages, clinical and analytical parameters, treatments modalities, and outcomes, and the accuracy of US for management decisions.

RESULTS

A total of 230 patients were included. Outpatient management was successful in 51/53 (96.23%) cases with ALCD stage 0 and 62/72 (86.11%) patients with stage 1A. There were no differences in age (p = 0.076) or the presence of pericolic air bubbles (p = 0.06) between patients who underwent admission or outpatient management. Clinical and analytical data, treatment decisions, and outcomes showed statistically significant differences between WSES stages. In 7/12 patients with stage 2A, percutaneous drainage or emergency surgery was required. All cases with stage 2B (distant air) underwent conservative management without the need for emergency or elective surgery. The accuracy of US WSES stages for management decisions, when compared with CT, was 96.96%.

CONCLUSION

The WSES classification for ALCD seemed to be valid helping clinicians in the decision-making process to select between admission or outpatient management. Differences in clinical and analytical data, elected treatments, and outcomes were found between WSES stages. The US WSES stages showed high accuracy for management decisions.

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

A case-report on diverticulitis misdiagnosed as tubo-ovarian abscess

Introduction and importance

Tubo-ovarian abscesses (TOA) is presented with multiple clinical manifestations including gastrointestinal findings.

Case presentation

Herein, we present a case of complicated diverticulitis that was misdiagnosed as TOA, owing to overlapping genital involvement.

Clinical discussion

Imaging could be misleading in these patients as a result of severe inflammation of intestines and surrounding organs.

Conclusion

Patients who do not respond to antibiotic treatment should be suspected of other gastrointestinal pathologies such as diverticulitis and should be evaluated accordingly.

•

Concomitant presentation of diverticulitis and Tubo-ovarian abscesses (TOA) has been rarely reported.

•

Diverticulitis can also be complicated, indicated by the involvement of other organs such as ovaries and fallopian tube.

•

In such cases, pathological evaluation, following the surgical intervention can indicate the exact disease.

Machine Learning Model for Outcome Prediction of Patients Suffering from Acute Diverticulitis Arriving at the Emergency Department-A Proof of Concept Study

Background & Aims: We aimed at identifying specific emergency department (ED) risk factors for developing complicated acute diverticulitis (AD) and evaluate a machine learning model (ML) for predicting complicated AD. Methods: We analyzed data retrieved from unselected consecutive large bowel AD patients from five hospitals from the Mount Sinai health system, NY. The study time frame was from January 2011 through March 2021. Data were used to train and evaluate a gradient-boosting machine learning model to identify patients with complicated diverticulitis, defined as a need for invasive intervention or in-hospital mortality. The model was trained and evaluated on data from four hospitals and externally validated on held-out data from the fifth hospital. Results: The final cohort included 4997 AD visits. Of them, 129 (2.9%) visits had complicated diverticulitis. Patients with complicated diverticulitis were more likely to be men, black, and arrive by ambulance. Regarding laboratory values, patients with complicated diverticulitis had higher levels of absolute neutrophils (AUC 0.73), higher white blood cells (AUC 0.70), platelet count (AUC 0.68) and lactate (AUC 0.61), and lower levels of albumin (AUC 0.69), chloride (AUC 0.64), and sodium (AUC 0.61). In the external validation cohort, the ML model showed AUC 0.85 (95% CI 0.78–0.91) for predicting complicated diverticulitis. For Youden’s index, the model showed a sensitivity of 88% with a false positive rate of 1:3.6. Conclusions: A ML model trained on clinical measures provides a proof of concept performance in predicting complications in patients presenting to the ED with AD. Clinically, it implies that a ML model may classify low-risk patients to be discharged from the ED for further treatment under an ambulatory setting.

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

PURPOSE/BACKGROUND

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

METHODS

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

RESULTS/OUTCOMES

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

CONCLUSION/DISCUSSION

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

Radiologic predictors for failure of non-operative management of complicated diverticulitis: a single-centre cohort study

PURPOSE

Modern non-operative management of diverticulitis consists of a complex therapeutic regimen and is successful in most cases even of complicated diverticulitis. Still, a certain proportion of patients requires urgent surgery due to failure of the conservative approach. This study aims to identify predictors for failure of conservative treatment of complicated diverticulitis with the need for subsequent urgent resection during the acute episode.

METHODS

A single-centre retrospective cohort study was performed at our tertiary centre including cases of acute complicated diverticulitis (characterized by localized abscess formation and/or pericolic air) between 2007 and 2019 that were treated guideline-conform by multimodal conservative treatment. Radiologic characteristics of disease in CT scans upon admission were analysed by uni- and multivariable logistic regression to determine predictors for resection within 30 days after onset of the conservative therapy approach.

RESULTS

A total of 669 cases of acute diverticulitis were identified, of which 141 patients met the inclusion criteria. Overall, 13% (n = 19) of patients were operated within 30 days despite initial conservative management. Multivariable logistic regression identified length of inflamed bowel greater than 7 cm (p < 0.011) and abscess formations >1 cm (p < 0.001) as significant risk factors for failure of conservative treatment.

CONCLUSION

Patients with length of inflamed bowel >7 cm or abscess formation >1 cm have increased risk for failure of conservative treatment of acute episodes of diverticulitis with contained perforations with subsequent need for urgent surgery. Therefore, conservative treatment of those patients should be monitored with special caution.

Relevance of pneumoperitoneum in the conservative approach to complicated acute diverticulitis. A retrospective study identifying risk factors associated with treatment failure

BACKGROUND

The aim was to evaluate the relevance of pneumoperitoneum on the success rate of non-operative management (NOM) of patients with complicated acute diverticulitis (AD), and the risk factors associated with failure.

METHODS

Observational retrospective cohort study of patients attended at the emergency department for AD from January 2015-August 2019. Patient demographics, blood tests, radiological data and initial treatment strategies were registered. NOM, based on intravenous antibiotics (ATB) and bowel rest, was defined as unsuccessful when emergency surgery (ES) and/or infection-related death took place. Patients initially treated with ES were excluded. Analysis was done with the IBM SPSS statistics 23.0.0.2 software.

RESULTS

According to modified Hinchey and WSES criteria, 99 (12%) of 826 AD episodes were complicated, with pneumoperitoneum on the CT scan in 89 (90.5%). NOM was undertaken in 93 (94%) cases, with a 91.5% success rate. Multivariate analysis revealed ASA class III-IV, and the presence of fluid collections >3cm in diameter, but not distant free air, to be associated with NOM failure. However, the success rate of NOM was significantly higher in patients with pericolic pneumoperitoneum (98.5%) than in those with distant free air (80%) (p=0.02). Risk factors of NOM failure were an advanced age, high CRP and WBC values, and the presence of free fluid in >2 abdominal quadrants.

CONCLUSIONS

NOM in hemodynamically stable patients with complicated AD is a safe and feasible approach, even in the context of distant free air. Nevertheless, patients with isolated pericolic air did better in our series.

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

BACKGROUND

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

METHOD

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared.

RESULTS

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

CONCLUSION

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study

Background

The management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease.

Methods

Patients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission.

Results

In total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation.

Conclusion

Non-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.

Post-colonoscopy diverticulitis: A systematic review

BACKGROUND

Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature.

AIM

To systematically review all available evidence to describe the incidence, clinical course with management and propose a definition.

METHODS

The databases PubMed, EMBASE and Cochrane databases were searched using with the keywords up to June 2020. Additional manual search was performed and cross-checked for additional references. Data collected included demographics, reason for colonoscopy, time to diagnosis, method of diagnosis (clinical vs imaging) and management outcomes.

RESULTS

A total of nine studies were included in the final systematic review with a total of 339 cases. The time to diagnosis post-colonoscopy ranged from 2 h to 30 d. Clinical presentation for these patients were non-specific including abdominal pain, nausea/vomiting, per rectal bleeding and chills/fever. Majority of the cases were diagnosed based on computed tomography scan. The management for these patients were similar to the usual patients presenting with diverticulitis where most resolve with non-operative intervention (i.e., antibiotics and bowel rest).

CONCLUSION

The entity of post-colonoscopy diverticulitis remains contentious where there is a wide duration post-procedure included. Regardless of whether this is a true complication post-colonoscopy or a de novo event, early diagnosis is vital to guide appropriate treatment. Further prospective studies especially registries should include this as a complication to try to capture the true incidence.

Update on the management of sigmoid diverticulitis

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

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

The Indications for and Timing of Surgery for Diverticular Disease

BACKGROUND

Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease.

METHODS

This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease.

RESULTS

Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails.

CONCLUSION

The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

Short- and Long-Term Outcomes of Right-Sided Diverticulitis: Over 15 Years of North American Experience

BACKGROUND

Right-sided colonic diverticulitis represents less than 5% of diverticulitis cases in North America. The purpose of this study was to describe the management and outcomes for patients with a first episode of right-sided diverticulitis in a North American center.

METHODS

This was a retrospective cohort study, including all patients managed for right-sided diverticulitis at a single tertiary-care institution from 2000 to 2017. Patient demographics, disease characteristics, and treatment strategies were described. Short- (emergency surgery, operative morbidity, treatment failure) and long-term (recurrence, elective operation) outcomes were reported. Patients with right-sided diverticulitis were then compared to a cohort of patients with left-sided diverticulitis.

RESULTS

Sixty-seven patients were managed for a first episode of right-sided diverticulitis, three (4.5%) of which were subsequently diagnosed with right-sided colon cancer; 64 patients therefore formed the population. Mean age was 51.2 ± 17.7 years. Eight patients (12.5%) self-identified as being Asian. The majority of patients had uncomplicated disease (90.6%); six (9.4%) presented with complicated diverticulitis. Most cases were diagnosed by computed tomography (78.1%), while 17.2% were diagnosed intra-operatively and 4.7% by pathology. Almost all patients diagnosed by computed tomography were managed nonoperatively. Fifteen patients (23.4%) were managed surgically: ten for suspected appendicitis, three for suspected colon mass, and two for diffuse peritonitis. After a median follow-up of 74.8 months (IQR 30.2-130.5), only two patients (3.1%) developed recurrent right-sided diverticulitis. Among patients managed nonoperatively, recurrence was significantly lower in patients with right-sided diverticulitis relative to left-sided diverticulitis (4.1% vs. 32.8%, p < 0.001).

CONCLUSIONS

Right-sided diverticulitis can be successfully managed nonoperatively with low rates of recurrence. In populations in which this condition is more seldom observed, underlying colon cancers should be considered.

Hinchey Ia acute diverticulitis with isolated pericolic air on CT imaging; to operate or not? A systematic review

BACKGROUND

Colonic diverticulitis is one of the most common gastrointestinal pathologies and its prevalence increases with the aging of the population in Western countries. Approximately 15% of patients with Hinchey Ia acute diverticulitis present with concomitant isolated pericolic air bubbles that denote intestinal perforation and thus prompting a more "aggressive" treatment attitude, including emergency surgery, despite the absence of evidence-based indications. This study is trying to delineate whether this approach is justified or whether a conservative treatment would suffice for this group of patients.

MATERIALS AND METHODS

PubMed and Cochrane CENTRAL databases were systematically searched in order to identify all studies that reported the need for emergency surgery and for percutaneous drainage in patients presenting with Hinchey Ia colonic diverticulitis with extraluminal pericolic gas on CT imaging who were initially treated conservatively. The last database search was performed on November 29, 2019 and no language or study type restriction criteria were applied. The Newcastle-Ottawa scale was used to assess the risk of bias of selected studies.

RESULTS

Nine observational cohort studies with 411 patients reported the need for emergency surgery, with a pooled rate of 5.1%. Among these studies, four studies comprising 165 patients reported the need for percutaneous drainage separately with a pooled rate of 1.2%.

CONCLUSION

Non-operative management of Hinchey Ia acute diverticulitis with isolated pericolic air is feasible and safe with a success rate of 94.9%. Abscess formation requiring percutaneous drainage is present in only 1.2% of patients, thus rendering the conservative initial treatment of these patients justified. Nevertheless, low quality of included studies indicates further research to validate the outcomes of this review.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

C-reactive protein trajectory in the first 48 hours predicts the need for intervention in conservative management of acute diverticulitis

BACKGROUND

C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD).

METHODS

A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: 'Low rise' (levels below median at day 0 and 2), 'High rise' (levels above median at day 0 and 2), 'Rapid rise' (levels below median at day 0 but above median at day 2) and 'Decline' (levels above median at day 0 but below median at day 2).

RESULTS

Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the 'Low rise', 76 (27%) in the 'Decline', 26 patients (9%) in the 'Rapid rise' and 25 patients (9%) in the 'High rise' groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2-59.4), P < 0.0001).

CONCLUSION

The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a 'Rapid rise' or 'High rise' in CRP from day 0 to 2 are more likely to need intervention.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Acute diverticulitis: old challenge, current trends, open questions

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

Diagnostic accuracy of acute diverticulitis with unenhanced low-dose CT

Background

The aim of this study was to evaluate the diagnostic accuracy of unenhanced low‐dose CT (LDCT) in acute colonic diverticulitis in comparison with contrast‐enhanced standard‐dose CT (SDCT).

Methods

All patients with clinically suspected diverticulitis who underwent LDCT followed by SDCT between January and October 2017 were evaluated prospectively. CT examinations were assessed for signs of diverticulitis, complications and other differential diagnoses by three independent radiologists (two consultants and one fourth‐year resident) using SDCT as the reference method. Sensitivity and specificity were calculated and Cohen's κ coefficient was used for agreement analyses.

Results

Of the 149 patients included (mean age 66·7 years, M : F ratio 0·4), 107 (71·8 per cent) had imaging consistent with diverticulitis on standard CT. Sensitivity and specificity values for a diverticulitis diagnosis using LDCT were 95–99 and 86–100 per cent respectively, and respective values for identification of complications were 58–73 and 78–100 per cent. The corresponding κ values among the three readers for diagnosis were 0·984, 0·934 and 0·816, whereas κ values for complications were 0·680, 0·703 and 0·354. Of the 26 patients who presented with other causes of abdominal symptoms identified on standard CT, 23 were diagnosed correctly on LDCT. Missed cases included splenic infarction (1) and segmental colitis (2).

Conclusion

The diagnostic accuracy of LDCT was high for the presence of acute diverticulitis. However, as signs of complicated disease can be missed using the low‐dose protocol, use of LDCT as a primary examination method should not preclude SDCT when complications may be suspected.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess

PURPOSE

The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess.

METHODS

Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition.

RESULTS

Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001).

CONCLUSION

The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

Free abdominal gas on computed tomography in the emergency department: aetiologies and association between amount of free gas and mortality

INTRODUCTION

Free abdominal gas is an important finding with major clinical implications. However, data on the aetiologies and prognosis of patients with free gas are scarce. Our primary aim was to describe the sources of free abdominal gas on emergency department (ED) computed tomography (CT). The secondary aim was to evaluate the association between the amount of free gas and all-cause mortality.

METHODS

All patients who underwent CT in the ED between February 2012 and February 2019 with free abdominal gas were included in the study. A scoring system was used to assess the amount of free gas: small - gas bubbles; medium - any gas pocket ≤2cm in diameter; large - any gas pocket >2cm. Data were collected from laboratory and clinical assessment regarding the source of free gas and all-cause mortality.

RESULTS

A total of 372 patients had free abdominal gas. Colonic diverticulitis was the most common aetiology among those with a small or medium amount of free gas (81/250 [32.4%] and 12/71 [16.9%] respectively). For patients with a large amount of gas, peptic disease was the most common aetiology (11/51 [21.6%]). Three-quarters of the patients (280/372, 75.2%) had the source of free gas identified during ED admission. Ninety-day mortality rates were 7.2%, 9.9% and 21.6% for patients with small, medium and large amounts of gas respectively (p=0.007).

CONCLUSIONS

Colonic diverticulitis was the most common source of free abdominal gas and peptic disease was the most common cause of a large amount of free gas. Mortality rates correlated with the amount of gas and were significantly higher in patients with a large amount.