1
|
Schena CA, Covino M, Laterza V, Quero G, La Greca A, Cina C, de'Angelis N, Marchegiani F, Sganga G, Gasbarrini A, Franceschi F, Longo F, Alfieri S, Rosa F. The role of procalcitonin as a risk stratification tool of severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. Surgery 2024; 176:162-171. [PMID: 38594101 DOI: 10.1016/j.surg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Imaging-based classifications do not always reflect the clinical severity and prognosis of acute left-sided colonic diverticulitis. This study aims to investigate the role of an early procalcitonin assessment in the emergency department as a risk stratification tool for severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. METHODS In this retrospective cohort study, all adult patients consecutively admitted from January 2015 to September 2020 for acute left-sided colonic diverticulitis and having a procalcitonin determination at admission were enrolled. The following data were collected: age, sex, comorbidities, laboratory parameters, level of urgency, clinical presentation, type of treatment, complications, and post-management outcomes. The association between the procalcitonin value at admission and the following endpoints was analyzed: type of treatment, classification of acute left-sided colonic diverticulitis, mortality, and type of surgery. RESULTS A total of 503 consecutive patients were enrolled. Procalcitonin >0.5 ng/mL emerged as an independent risk factor for complicated acute left-sided colonic diverticulitis (P = .007). Procalcitonin >0.5 ng/mL (P = .033), together with a history of complicated acute left-sided colonic diverticulitis (P < .001), abdominal pain (P = .04), bowel perforation (P < .001), and peritonitis (P < .001), was a significant risk factor for surgery. Procalcitonin >0.5 ng/mL (P = .007) and peritonitis (P = .03) emerged as independent risk factors for sigmoidectomy without colorectal anastomosis. Procalcitonin >0.5 ng/mL (P = .004), a higher level of urgency at admission (P = .005), Hartmann's procedure (P = .002), and the necessity of mechanical ventilation (P = .004) emerged as independent risk factors for mortality. CONCLUSION Procalcitonin >0.05 ng/mL at emergency department admission is a useful risk stratification tool for severity, prognosis, and need for surgical treatment in patients with acute left-sided colonic diverticulitis.
Collapse
Affiliation(s)
- Carlo Alberto Schena
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marcello Covino
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Vito Laterza
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, France.
| | - Giuseppe Quero
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio La Greca
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Caterina Cina
- Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Gabriele Sganga
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Franceschi
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Fabio Longo
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Sergio Alfieri
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fausto Rosa
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| |
Collapse
|
2
|
Carmona Agúndez M, Gallarín Salamanca IM, Salas Martínez J. Free perforation during the first episode of acute diverticulitis: can it be avoided? Updates Surg 2024; 76:521-528. [PMID: 38168842 DOI: 10.1007/s13304-023-01743-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016-1.067), lung disease (OR 2.154 95% CI 1.038-4.472) and immunosuppression (OR: 2.812 95% CI 1.315-6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes.
Collapse
Affiliation(s)
- María Carmona Agúndez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Badajoz, Badajoz, Spain.
| | | | - Jesús Salas Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Badajoz, Badajoz, Spain
| |
Collapse
|
3
|
Bormann SL, Wood R, Guido JM. Hoarseness due to subcutaneous emphysema: a rare presentation of diverticular perforation. J Surg Case Rep 2024; 2024:rjad566. [PMID: 38495049 PMCID: PMC10941808 DOI: 10.1093/jscr/rjad566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/09/2023] [Indexed: 03/19/2024] Open
Abstract
Pneumomediastinum and subcutaneous emphysema usually result from alveolar rupture and rarely from colonic perforation. Although steroid use has been shown to increase the risk of complicated diverticulitis, there is limited data on the role Addison's disease may play in the development of colonic perforation. We present a rare case of a patient with Addison's disease who presented with hoarseness and was found to have massive subcutaneous emphysema, pneumomediastinum, and pneumoretroperitoneum secondary to complicated diverticulitis.
Collapse
Affiliation(s)
- Sydney L Bormann
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57105, United States
| | - Rebekah Wood
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57105, United States
| | - Jenny M Guido
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD 57105, United States
| |
Collapse
|
4
|
Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. Am J Emerg Med 2024; 76:1-6. [PMID: 37956503 DOI: 10.1016/j.ajem.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with acute diverticulitis.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessie Werner
- Department of Emergency Medicine, UCSF Fresno, Fresno, CA, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
5
|
Williams B, Gupta A, Koller SD, Starr TJ, Star MJH, Shaw DD, Hakim AH, Leinicke J, Visenio M, Perrone KH, Torgerson ZH, Person AD, Ternent CA, Chen KA, Kapadia MR, Keller DS, Elnagar J, Okonkwo A, Gagliano RA, Clark CE, Arcomano N, Abcarian AM, Beaty JS. Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know. Curr Probl Surg 2024; 61:101427. [PMID: 38161059 DOI: 10.1016/j.cpsurg.2023.101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Brian Williams
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Abhinav Gupta
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Sarah D Koller
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Tanya Jt Starr
- Health Corporation of America, Midwest Division, Kansas City, KS
| | | | - Darcy D Shaw
- Health Corporation of America, Midwest Division, Kansas City, KS
| | - Ali H Hakim
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Leinicke
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael Visenio
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Kenneth H Perrone
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | | | - Austin D Person
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Charles A Ternent
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Kevin A Chen
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Muneera R Kapadia
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Deborah S Keller
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA; Marks Colorectal Surgical Associates, Wynnewood, PA
| | - Jaafar Elnagar
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA
| | | | | | | | - Nicolas Arcomano
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Ariane M Abcarian
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Cook County Health, Chicago, IL
| | | |
Collapse
|
6
|
Ocaña J, García-Pérez JC, Fernández-Martínez D, Aguirre I, Pascual I, Lora P, Espin-Basany E, Labalde-Martínez M, León C, Pastor-Peinado P, López-Domínguez C, Muñoz-Plaza N, Valle A, Dujovne P, Alías D, Pérez-Santiago L, Correa A, Carmona M, Fernández-Cebrián JM, Die J. Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group. Colorectal Dis 2024; 26:120-129. [PMID: 38010046 DOI: 10.1111/codi.16810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/27/2023] [Accepted: 09/22/2023] [Indexed: 11/29/2023]
Abstract
AIM Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery. METHODS A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS. RESULTS A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS. CONCLUSION Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.
Collapse
Affiliation(s)
- Juan Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Carlos García-Pérez
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ignacio Aguirre
- Colorectal Surgery Unit, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Isabel Pascual
- Colorectal Division, Hospital Universitario La Paz, Madrid, Spain
| | - Paola Lora
- Colorectal Division, Hospital Univseristario Cabueñes, Gijón, Spain
| | - Eloy Espin-Basany
- Department of Colorectal Surgery, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Carmen León
- Division of Coloproctology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Paula Pastor-Peinado
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Nerea Muñoz-Plaza
- Division of Coloproctology, Hospital Universitario Burgos, Burgos, Spain
| | - Ainhoa Valle
- Division of Coloproctology, Hospital Universitario de Getafe, Getafe, Spain
| | - Paula Dujovne
- Division of Coloproctology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - David Alías
- Unit of Coloproctology, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
| | | | - Alba Correa
- Unit of Coloproctology, Hospital Universitario La Princesa, Madrid, Spain
| | - María Carmona
- Division of Coloproctology, Hospital Universitario de Badajoz, Badajoz, Spain
| | - José María Fernández-Cebrián
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Die
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| |
Collapse
|
7
|
Ocaña J, García-Pérez JC, Fernández-Martínez D, Aguirre I, Pascual I, Lora P, Espin E, Labalde-Martínez M, León C, Pastor-Peinado P, López-Domínguez C, Muñoz-Plaza N, Valle A, Dujovne P, Alías D, Pérez-Santiago L, Correa A, Carmona M, Díez MM, Timoteo A, Salvans S, Medina RE, Gómez T, Fernández-Vega L, Peña E, García-González JM, Blanco-Antona F, Fábregues AI, Sagarra E, Viejo E, Moreno A, Fernández-Cebrián JM, Die J. Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group. Surgery 2023; 174:492-501. [PMID: 37385866 DOI: 10.1016/j.surg.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. METHODS This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. RESULTS Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85). CONCLUSION Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.
Collapse
Affiliation(s)
- Juan Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Juan Carlos García-Pérez
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ignacio Aguirre
- Colorectal Surgery Unit, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Isabel Pascual
- Colorectal Division, Hospital Universitario La Paz, Madrid, Spain
| | - Paola Lora
- Colorectal Division, Hospital Univseristario Cabueñes, Gijón, Spain
| | - Eloy Espin
- Department of Colorectal Surgery, Hospital Universitari Vall d´Hebron, Universitat Autonoma de Barcelona, Spain
| | | | - Carmen León
- Division of Coloproctology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Paula Pastor-Peinado
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | | | - Ainhoa Valle
- Division of Coloproctology, Hospital Universitario de Getafe, Spain
| | - Paula Dujovne
- Division of Coloproctology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - David Alías
- Unit of Coloproctology, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
| | | | - Alba Correa
- Unit of Coloproctology, Hospital Universitario La Princesa, Madrid, Spain
| | - María Carmona
- Division of Coloproctology, Hospital Universitario de Badajoz, Spain
| | - Manuel Mariano Díez
- Division of Coloproctology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain
| | - Ander Timoteo
- Division of Coloproctology, Hospital Universitari Dr Josep Trueta, Gerona, Spain
| | - Silvia Salvans
- Division of Coloproctology, Hospital del Mar, Barcelona, Spain
| | - Rita Esther Medina
- Division of Coloproctology, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Tatiana Gómez
- Division of Coloproctology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - Emilio Peña
- Division of Coloproctology, Hospital Universitario Reina Sofía, Murcia, Spain
| | | | | | | | - Elena Sagarra
- Division of Coloproctology, Hospital Universitario Infanta Cristina, Parla, Spain
| | - Elena Viejo
- Division of Coloproctology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Araceli Moreno
- Division of Coloproctology, Hospital Reina Sofía, Córdoba, Spain
| | - José María Fernández-Cebrián
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Die
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| |
Collapse
|
8
|
Matthes A, Wolf F, Wilde E, Bleidorn J, Markwart R. Point-of-care measurement of C-reactive protein promotes de-escalation of treatment decisions and strengthens the perceived clinical confidence of physicians in out-of-hours outpatient emergency medical services. BMJ Open 2023; 13:e069453. [PMID: 37147098 PMCID: PMC10163444 DOI: 10.1136/bmjopen-2022-069453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES Out-of-hours outpatient emergency medical services (OEMS) provide healthcare for patients with non-life-threatening conditions in need for urgent care when outpatient practices are closed. We studied the use of point-of-care-testing of C-reactive protein (CRP-POCT) at OEMS. DESIGN Cross-sectional questionnaire-based survey. SETTING Single centre OEMS practice in Hildesheim, Germany (October 2021 to March 2022). PARTICIPANTS OEMS physicians answering a questionnaire immediately after performing CRP-POCTs (CUBE-S Analyzer, Hitado) on any patients. PRIMARY AND SECONDARY OUTCOMES Impact of CRP-POCTs on clinical decision-making and perceived usefulness. RESULTS In the 6-month study period, 114 valid CRP-POCTs were performed in the OEMS practice by 18 physicians and the questionnaire was answered in 112 cases (response rate: 98.2%). CRP-POCTs were used in the diagnosis of inflammatory diseases of the gastrointestinal tract (60.0%), respiratory tract infections (17.0%), urinary tract infections (9.0%) and other non-gastrointestinal/non-specified infections (11.0%). The use of a CRP-POCT resulted in a change of the physicians' clinical decision in 83.3% of the cases. Specifically, in 13.6% and 35.1% of the cases, rapid CRP measurements led to decision changes in the (1) initiation of antimicrobial therapy and (2) other drug treatment, respectively. Notably, in 60% of all cases, the use of a CRP-POCT reportedly changed the decision on hospitalisation/non-hospitalisation of OEMS patients. In respect of antimicrobial therapy and hospitalisation, these decision changes primarily (≥73%) promoted 'step-down' decisions, that is, no antibiotic therapy and no hospital admission. In the great majority of CRP-POCT applications (≥95%), OEMS physicians reported that rapid CRP measurements increased the confidence in their diagnostic and therapeutic decision. In almost all cases (97%), physicians rated the CRP-POCT use as useful in the treatment situation. CONCLUSION Quantitative CRP-POCT promotes step-down clinical decisions and strengthens the clinical confidence of physicians in out-of-hours OEMS.
Collapse
Affiliation(s)
- Anni Matthes
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- InfectoGnostics Research Campus Jena, Jena, Germany
| | - Florian Wolf
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Elmar Wilde
- Practice Network HilMed Hildesheim, Hildesheim, Germany
| | - Jutta Bleidorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Robby Markwart
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- InfectoGnostics Research Campus Jena, Jena, Germany
| |
Collapse
|
9
|
Portolese AC, McMullen BN, Baker SK, Chen See JR, Yochum GS, Koltun WA, Lamendella R, Jeganathan NA. The Microbiome of Complicated Diverticulitis: An Imbalance of Sulfur-Metabolizing Bacteria. Dis Colon Rectum 2023; 66:707-715. [PMID: 36856684 DOI: 10.1097/dcr.0000000000002647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND The progression to acute diverticulitis from the relatively benign condition of colonic diverticulosis is not well characterized. A smaller subset may even develop complicated (perforated) diverticulitis resulting in sepsis and/or death. Characterizing the differences between recurrent, uncomplicated diverticulitis, and the more virulent, complicated diverticulitis is necessary to guide clinical decision-making. Alterations to the microbiome offer a possible explanation for local inflammation and the pathophysiology of diverticular disease. OBJECTIVE This study aimed to characterize the mucosal-associated microbiome in patients with recurrent uncomplicated diverticulitis and complicated (perforated) diverticulitis. DESIGN Microbial DNA was extracted from full-thickness surgical specimens for 16S rRNA gene sequencing, targeting the V4 hypervariable region. Sequences were analyzed and a quantitative characterization based on taxonomic classification was performed. SETTING A tertiary care academic medical center. PATIENTS This study compared 48 patients with recurrent, uncomplicated diverticulitis and 35 patients with radiographically confirmed perforated (complicated) diverticulitis. Tissues were harvested from surgical resection specimens to include both diseased regions and nondiseased (adjacent normal) regions. MAIN OUTCOME MEASURES We assessed differences in relative abundance and taxonomic classification of mucosal-associated microbes in surgical resection specimens from diverticular disease. RESULTS When analyzing the tissue of diverticular resection specimens, the complicated diseased segments demonstrated an increased abundance of sulfur-reducing and sulfur-oxidizing bacteria compared to nondiseased, adjacent normal regions. When comparing diseased segments, tissues of patients with complicated diverticulitis had a marked increase in sulfur-reducing microbes. LIMITATIONS We characterized the mucosal-associated microbiome present at the time of surgical resection, limiting conclusions on its role in pathophysiology. Furthermore, antibiotic usage and bowel preparation before surgery may result in perturbations to microbial flora. CONCLUSIONS The microbiome of complicated diverticulitis is marked by a localized imbalance of sulfur-metabolizing microbes. The abundance of sulfur-reducing microbes may lead to an excess of hydrogen sulfide and subsequent inflammation. See Video Abstract at http://links.lww.com/DCR/C175 . LA MICROBIOMA DE LA DIVERTICULITIS COMPLICADA UN DESEQUILIBRIO DE LAS BACTERIAS METABOLIZADORAS DE AZUFRE ANTECEDENTES: La progresión a diverticulitis aguda de la condición relativamente benigna de diverticulosis colónica no está bien caracterizada. Un subgrupo más pequeño puede incluso desarrollar diverticulitis complicada (perforada) que resulta en sepsis y/o muerte. Es necesario caracterizar las diferencias entre la diverticulitis recurrente no complicada y la diverticulitis complicada más virulenta para guiar la toma de decisiones clínicas. Las alteraciones del microbioma ofrecen una posible explicación de la inflamación local y la fisiopatología de la enfermedad diverticular.OBJETIVO: Caracterizar el microbioma asociado a la mucosa en pacientes con diverticulitis no complicada recurrente y diverticulitis complicada (perforada).DISEÑO: El ADN microbiano se extrajo de especímenes quirúrgicos de espesor completo para la secuenciación del gen 16S rRNA, dirigido a la región hipervariable V4. Se analizaron las secuencias y se realizó una caracterización cuantitativa basada en la clasificación taxonómica.AJUSTE: Un centro médico académico de atención terciaria.PACIENTES: Este estudio comparó 48 pacientes con diverticulitis recurrente no complicada y 35 pacientes con diverticulitis perforada (complicada) confirmada radiográficamente. Se recogieron tejidos de especímenes de resección quirúrgica para incluir tanto regiones enfermas como regiones no enfermas (normales adyacentes).PRINCIPALES MEDIDAS DE RESULTADO: Evaluamos las diferencias en la abundancia relativa y la clasificación taxonómica de los microbios asociados a la mucosa en muestras de resección quirúrgica de enfermedad diverticular.RESULTADOS: Al analizar el tejido de las muestras de resección diverticular, los segmentos enfermos complicados demostraron una mayor abundancia de bacterias reductoras de azufre y oxidantes de azufre en comparación con las regiones normales adyacentes no enfermas. Al comparar segmentos enfermos, los tejidos de pacientes complicados tenían un marcado aumento de microbios reductores de azufre.LIMITACIONES: Caracterizamos el microbioma asociado a la mucosa presente en el momento de la resección quirúrgica, lo que limita las conclusiones sobre su papel en la fisiopatología. Además, el uso de antibióticos y la preparación intestinal antes de la cirugía pueden provocar alteraciones en la flora microbiana.CONCLUSIONES: El microbioma de la diverticulitis complicada está marcado por un desequilibrio localizado de microbios metabolizadores de azufre. La abundancia de microbios reductores de azufre puede provocar un exceso de sulfuro de hidrógeno y la consiguiente inflamación. Consulte Video Resumen en http://links.lww.com/DCR/C175 . (Traducción-Dr. Ingrid Melo ).
Collapse
Affiliation(s)
- Austin C Portolese
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Samantha K Baker
- Department of Biology, Juniata College, Huntingdon, Pennsylvania
| | | | - Gregory S Yochum
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
- Department of Biochemistry and Molecular Biology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Walter A Koltun
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Regina Lamendella
- Department of Biological Sciences, Juniata College, Huntington, Pennsylvania
| | - Nimalan A Jeganathan
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
10
|
Abet E, Bawjeski S, Planche L, Weyd B, de Kerviler B. Evaluation of a treatment pathway for the management of uncomplicated diverticulitis. J Visc Surg 2023; 160:27-32. [PMID: 35459631 DOI: 10.1016/j.jviscsurg.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Recent clinical practice recommendations have radically modified the management of colonic diverticulitis. The goal of our study was to evaluate a treatment pathway for uncomplicated diverticulitis and to analyze the outcome (patient compliance, treatment failure and complications). PATIENTS AND METHODS All patients who presented to the emergency department with the diagnosis of uncomplicated diverticulitis were prospectively included in this study. The treatment pathway included an outpatient clinical re-assessment by a gastrointestinal surgeon. In case of symptomatic treatment failure, oral antibiotics were prescribed. If developed clinical signs of severity developed, the patient was referred to the emergency department for new laboratory and imaging workup. RESULTS Eighty-seven patients were included. The mean interval before re-assessment was 2.8 days. Fifty-nine patients (67.8%) had symptomatic treatment upon discharge from the emergency department and were reassessed as outpatients by the surgical team. Patient evolution was satisfactory for 45 (76.3%); 10 (16.9%) required oral antibiotics. One (1.7%) patient developed complicated diverticulitis. Thirty-four (39.1%) patients did not comply with the current recommendations. CONCLUSION In our experience, uncomplicated diverticulitis can be treated effectively in an ambulatory setting followed by early re-assessment by a surgeon.
Collapse
Affiliation(s)
- E Abet
- Department of digestive surgery, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France.
| | - S Bawjeski
- Emergency department, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - L Planche
- Clinical research unit, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - B Weyd
- Emergency department, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - B de Kerviler
- Department of digestive surgery, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| |
Collapse
|
11
|
Metastatic Hepatocellular Carcinoma Masquerading as Acute Diverticulitis. ACG Case Rep J 2022; 9:e00913. [PMID: 36447772 PMCID: PMC9699498 DOI: 10.14309/crj.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 01/25/2023] Open
Abstract
Colorectal cancer may masquerade as acute diverticulitis. Our case is a 71-year-old man who presented to the emergency department with abdominal pain and was diagnosed with acute diverticulitis. He was ultimately found to have metastatic hepatocellular carcinoma to the colon without any evidence of diverticular disease on colonoscopy. Although the most common malignancy to masquerade as diverticulitis is colorectal cancer, metastatic deposits should also be considered, especially in patients with a history of extracolonic malignancy.
Collapse
|
12
|
Pavlidis ET, Pavlidis TE. Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review. Cureus 2022; 14:e28446. [PMID: 36176861 PMCID: PMC9509703 DOI: 10.7759/cureus.28446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 02/05/2023] Open
Abstract
Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann's sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey's classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).
Collapse
Affiliation(s)
- Efstathios T Pavlidis
- 2nd Surgical Propedeutic Department, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, GRC
| | - Theodoros E Pavlidis
- 2nd Surgical Propedeutic Department, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, GRC
| |
Collapse
|
13
|
Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Turner GA, O'Grady MJ, Purcell RV, Frizelle FA. Acute Diverticulitis in Young Patients: A Review of the Changing Epidemiology and Etiology. Dig Dis Sci 2022; 67:1156-1162. [PMID: 33786702 DOI: 10.1007/s10620-021-06956-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/12/2021] [Indexed: 12/19/2022]
Abstract
Acute diverticulitis is one of the leading gastrointestinal causes for hospitalization. The incidence of acute diverticulitis has been increasing in recent years, especially in patients under 50 years old. Historically, acute diverticulitis in younger patients was felt to represent a separate entity, being more virulent and associated with a higher rate of recurrence. Accordingly, young patients were often managed differently to older counterparts. Our understanding of the natural history of this condition has evolved, and current clinical practice guidelines suggest age should not alter management. The purpose of this review is to evaluate the changing epidemiology of acute diverticulitis, consider potential explanations for the observed increased incidence in younger patients, as well as review the natural history of acute diverticulitis in the younger population.
Collapse
Affiliation(s)
- Greg A Turner
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand.
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand.
| | - Michael J O'Grady
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Rachel V Purcell
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Frank A Frizelle
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
- Department of Surgery, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| |
Collapse
|
15
|
DeLong CG, Scow JS, Morrell DJ, Knoedler JJ, Alli VV, Winder JS, Pauli EM. Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series. Colorectal Dis 2022; 24:314-321. [PMID: 34762356 DOI: 10.1111/codi.15987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 12/09/2022]
Abstract
AIM Conventional surgical management of colovesical and colovaginal fistulas can be morbid and is contraindicated in many patients. Our aim in this work is to evaluate our experience in the management of colovesical and colovaginal fistulas with endoscopic over-the-scope (OTS) clips. METHOD A retrospective review of all patients who underwent attempted endoscopic OTS clip management of colovesical and colovaginal fistulas between 2013 and 2020 was performed. Preoperative risk factors, operative details and postoperative outcomes are reported. RESULTS Ten patients were identified. Fistula types were: colovesical (five), rectovesical (two), colovaginal (two) and rectovaginal (one). The aetiology of the fistula was diverticular disease in seven (70%) cases and surgical complication of pelvic surgery in three (30%). The mean defect age was 157 ± 98 days, the mean defect diameter was 4.5 mm (range 2-10 mm) and the mean fistula length was 15 mm (range 2-25 mm). In nine (90%) cases, fistula identification and cannulation were performed through the nonenteric lumen of the fistula. Initial management with an OTS clip was technically successful in eight (80%) patients. Of the eight patients who underwent OTS clip placement, long-term success (mean follow-up 218 days, range 25-673 days) was achieved after initial intervention in four (50%) patients. One patient underwent serial OTS clip procedures and achieved long-term success after four interventions; three patients have not undergone a repeat procedure after initial failure. CONCLUSION Endoscopic management of colovesical and colovaginal fistulas with OTS clips offers a promising therapeutic option for patients with contraindications to conventional surgical management. Immediate technical success and long-term success rates are similar to other gastrointestinal tract applications of OTS clips.
Collapse
Affiliation(s)
- Colin G DeLong
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jeffrey S Scow
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - David J Morrell
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John J Knoedler
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Vamsi V Alli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Joshua S Winder
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eric M Pauli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
16
|
Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial. Int J Surg 2022; 98:106221. [PMID: 35026462 DOI: 10.1016/j.ijsu.2021.106221] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis. METHODS Data were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality. RESULTS Three years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538-3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5-22.5) versus HP 17 days (IQR 12.5-27.5)), p = 0.025). CONCLUSION Long-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias.
Collapse
|
17
|
Frequency of Bowel Movements and Risk of Diverticulitis. Clin Gastroenterol Hepatol 2022; 20:325-333.e5. [PMID: 33418133 PMCID: PMC8957846 DOI: 10.1016/j.cgh.2021.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/29/2020] [Accepted: 01/01/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The etiology of diverticulitis is poorly understood. The long-held belief that constipation and low-fiber diet are risk factors for diverticulosis has recently been challenged by studies that suggest that more frequent bowel movements predispose to diverticulosis. We aim to prospectively explore the association between bowel movement frequency and incident diverticulitis. DESIGN We studied participants of the Nurses' Health Study (NHS) and Health Professional Follow-up Study (HPFS). Participants' medical history, lifestyle factors and diet were used in Cox proportional hazards regression models to estimate multivariable-adjusted hazard ratios(HRs) and 95% confidence intervals(CI). RESULTS In the NHS during over 24 years of follow-up encompassing 1,299,922 person-years, we documented 5,214 incident cases of diverticulitis, and in the HPFS over 14 years encompassing 368,661 person-years of follow-up, we documented 390 incident cases of diverticulitis. We observed an inverse association between the frequency of bowel movements and risk of diverticulitis. In the NHS, compared with women who had daily bowel movements, those with more than once daily bowel movements had a HR of 1.30 (95% CI, 1.19, 1.42) and those with less frequent bowel movements had a HR of 0.89 (95% CI, 0.82, 0.95; p-trend < 0.0001). In the HPFS, the corresponding HRs were 1.29 (95% CI, 1.04, 1.59) and 0.61 (95% CI, 0.36, 1.03; p-trend = 0.003). The association between bowel movements and diverticulitis was not modified by categories of age, BMI, physical activity, laxative use or fiber intake. CONCLUSION More frequent bowel movements appear to be a risk factor for subsequent diverticulitis both in men and women. Further studies are needed to understand the potential mechanisms that may underlie this association.
Collapse
|
18
|
Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
19
|
Machine Learning Model for Outcome Prediction of Patients Suffering from Acute Diverticulitis Arriving at the Emergency Department-A Proof of Concept Study. Diagnostics (Basel) 2021; 11:diagnostics11112102. [PMID: 34829448 PMCID: PMC8625306 DOI: 10.3390/diagnostics11112102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 12/23/2022] Open
Abstract
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.
Collapse
|
20
|
Böhm SK. Excessive Body Weight and Diverticular Disease. Visc Med 2021; 37:372-382. [PMID: 34722720 PMCID: PMC8543333 DOI: 10.1159/000518674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/23/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The worldwide proportion of overweight adults almost doubled from 22% in 1975 to 39% in 2016. Comparably, for the USA and Germany in 2016, the proportion was 68 and 56.8%, respectively. In Olmsted County, Minnesota, the prevalence of diverticulitis also doubled between 1980 and 2007, from 19 to 40%. Obesity substantially increases the risk of multiple gastrointestinal (GI) diseases and non-GI diseases. In a narrative review, we examined the evidence on whether obesity also increases the risk for the development of diverticulosis or diverticular disease and its outcome. SUMMARY Evidence suggests that being overweight (body mass index ≥25 kg/m2) or obese (≥30 kg/m2), especially viscerally obese, is a risk factor for diverticulosis, diverticular disease and diverticulitis, diverticular bleeding, more severe or complicated disease, recurrent disease, and for worse outcomes after surgery. KEY MESSAGES There is a well-founded association between overweight and diverticular disease as well as diverticulosis. It is not clear whether overweight per se or confounders linked with it are responsible for the association. However, means to fight the overweight and obesity epidemic might also help to reduce the prevalence of morbidity and mortality from diverticular disease.
Collapse
Affiliation(s)
- Stephan K. Böhm
- Klinik Innere Medizin/Gastroenterologie, Spital Bülach, Bülach, Switzerland
| |
Collapse
|
21
|
Lee SGW, Shin SD, Lee HJ, Suh GJ, Park DJ. Development of a prediction model for clinically important outcomes of acute diverticulitis. Am J Emerg Med 2021; 50:27-35. [PMID: 34271232 DOI: 10.1016/j.ajem.2021.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED. METHODS Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples. RESULTS Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/μl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ2 was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861). CONCLUSION A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.
Collapse
Affiliation(s)
- Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Do Joong Park
- Department of Surgery, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| |
Collapse
|
22
|
Lenti MV, Aronico N, Giuffrida P, Costa S, Costetti M, Musacchio C, Pastorelli L, Mengoli C, Borrelli de Andreis F, Cococcia S, Tinelli C, Klersy C, Vecchi M, Pilotto A, Di Sabatino A. Multidimensional Prognostic Index Predicts Clinical Outcome and Mortality in Hospitalised Older Patients with Diverticular Disease. Gerontology 2021; 68:44-52. [PMID: 33849017 DOI: 10.1159/000515161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 02/11/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Multidimensional Prognostic Index (MPI) is a validated tool for assessing mortality risk in hospitalised patients. We aimed to evaluate whether the MPI predicted mortality and the risk of developing diverticular disease (DD) complications in older patients. METHODS This is a multicentre study conducted in January 2016-March 2018. All patients with DD aged 65 years and older were included. Patients were stratified into three groups according to MPI groups (1, low risk; 2, moderate risk; 3, high risk). Risk of developing DD complications and mortality rate were assessed. Bivariate models were fitted. RESULTS One hundred hospitalised patients with DD (mean age 77.9 ± 10.6 years, 53 female patients) were included. Patients with higher MPI groups were more likely to develop DD complications. In particular, 12 (46.2%), 21 (52.5%), and 28 (82.4%) patients with complicated DD were distributed to the MPI 1, MPI 2, and MPI 3 groups (p = 0.0063), respectively. Two patients died in the MPI 1, 4 in the MPI 2, and 29 in the MPI 3 group, with mortality rates of 4.0 per 100 person-year (95% confidence interval [CI] 1.0-15.9), 5.6 (95% CI 2.1-15.0), and 89.2 (95% CI 62-130), respectively (log-rank test p < 0.001). In bivariate analysis, after adjustment for age >80 years, Charlson Comorbidity Index >4, DD complications, and the presence of thromboembolism, higher MPI group was independently associated with higher mortality. Those in the MPI 3 group experienced a greater risk of 1-year hospital readmission (p < 0.001). CONCLUSION MPI predicted mortality in patients with DD and also correlated with the risk of developing DD complications. Studies focussing on possible pathophysiological mechanisms between DD complications and MPI are needed.
Collapse
Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Nicola Aronico
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Paolo Giuffrida
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Stefania Costa
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Martina Costetti
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Clarissa Musacchio
- Geriatrics Unit, Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Genova, Italy
| | - Luca Pastorelli
- Department of Gastroenterology and Digestive Endoscopy Unit, IRCCS San Donato Hospital Foundation, University of Milan, San Donato Milanese, Milan, Italy
| | - Caterina Mengoli
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | | | - Sara Cococcia
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Carmine Tinelli
- Service of Biometry and Statistics, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Catherine Klersy
- Service of Biometry and Statistics, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, IRCCS Ca' Granda Hospital Foundation, University of Milan, Milan, Italy
| | - Alberto Pilotto
- Geriatrics Unit, Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Genova, Italy.,Department of Interdisciplinary Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| |
Collapse
|
23
|
Savoie-Hontoria M, Orti-Rodríguez RJ, García Bello MÁ, Pérez Álvarez AD, Barrera Gómez MÁ. Seeking outpatient management of right-sided diverticulitis. Eur Surg 2021. [DOI: 10.1007/s10353-021-00702-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
24
|
Sartelli M, Ansaloni L, Bartoletti M, Catena F, Cardi M, Cortese F, Di Marzo F, Pea F, Plebani M, Rossolini GM, Sganga G, Viaggi B, Viale P. The role of procalcitonin in reducing antibiotics across the surgical pathway. World J Emerg Surg 2021; 16:15. [PMID: 33761972 PMCID: PMC7988639 DOI: 10.1186/s13017-021-00357-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 12/29/2022] Open
Abstract
Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel.
Collapse
Affiliation(s)
| | | | - Michele Bartoletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Maurizio Cardi
- Department of Surgery, “P. Valdoni” Sapienza University, Rome, Italy
| | - Francesco Cortese
- Department of Emergency Surgery, San Filippo Neri Hospital, Roma, Italy
| | | | - Federico Pea
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine, University of Padova, Padova, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| |
Collapse
|
25
|
Covino M, Papa V, Tursi A, Simeoni B, Lopetuso LR, Vetrone LM, Franceschi F, Rapaccini G, Gasbarrini A, Papa A. Development and Validation of Predictive Assessment of Complicated Diverticulitis Score. J Pers Med 2021; 11:jpm11020080. [PMID: 33572940 PMCID: PMC7911244 DOI: 10.3390/jpm11020080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex (p < 0.001), constipation (p = 0.002), hemoglobin < 11.9 g/dL (p < 0.001), C reactive protein > 80 mg/L (p < 0.001), severe obesity (p = 0.049), and no proton pump inhibitor treatment (p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.
Collapse
Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Valerio Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, 70031 Andria, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
| | - Loris Riccardo Lopetuso
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Lorenzo Maria Vetrone
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Gianludovico Rapaccini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Alfredo Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-0151
| |
Collapse
|
26
|
Lorenzo-Zúñiga V, Bustamante-Balén M, Pons-Beltrán V. But, what are you telling me? GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:572. [PMID: 33187745 DOI: 10.1016/j.gastrohep.2020.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - Marco Bustamante-Balén
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Vicente Pons-Beltrán
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, España
| |
Collapse
|
27
|
Vaxman I, Al Saleh AS, Kumar S, Nitin M, Dispenzieri A, Buadi F, Dingli D, Lacy M, Muchtar E, Hobbs M, Fonder A, Hwa L, Visram A, Kapoor P, Siddiqui M, Lust J, Kyle R, Rajkumar V, Hayman S, Leung N, Gonsalves W, Kourelis T, Warsame R, Gertz MA. Colon perforation in multiple myeloma patients - A complication of high-dose steroid treatment. Cancer Med 2020; 9:8895-8901. [PMID: 33022868 PMCID: PMC7724303 DOI: 10.1002/cam4.3507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/19/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal complications of multiple myeloma (MM) treatment are common and include nausea, constipation, and diarrhea. However, acute gastrointestinal events like perforations are rare. We aimed to describe the characteristics and outcomes of patients with MM that had colonic perforations during their treatment. This is a retrospective study that included patients from all three Mayo Clinic sites who had MM and developed a colonic perforation. All patients were diagnosed with colonic perforations based on CT scans and were surgically treated. Patients diagnosed with AL amyloidosis, a perforated colon complicating neutropenic colitis during ASCT and those with perforation due to colonic cancer were excluded. A high dose of dexamethasone was defined as ≥40 mg dexamethasone once a week. Thirty patients met inclusion criteria. All patients received steroids at doses ≥10 mg once weekly prior to the perforation, while four (11%) were on high-dose dexamethasone without chemotherapy. Fourteen patients were given high doses of dexamethasone. Twenty-five patients required ostomies with all surviving surgery. Twenty-four perforations (80%) were associated with diverticulitis. Treatment with steroids was resumed in 23 patients with no further gastrointestinal complications. The median OS was 20 months following perforation (IQR 8-59). Within the same timeframe 5854 patients were treated at Mayo Clinic for MM, making the risk of bowel perforation 0.5%. Intestinal perforations in MM are rare and, in our series, always occurred with dexamethasone ≥10 mg per week. Urgent surgery is lifesaving and resumption of anti-myeloma treatment appears to be safe.
Collapse
Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Abdullah S Al Saleh
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Mishra Nitin
- Division of Colon and Rectal Surgery, Mayo Clinic, Scottsda, AZ, USA
| | | | - Francis Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Miriam Hobbs
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Amie Fonder
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Alissa Visram
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - John Lust
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Robert Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
28
|
Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020; 22 Suppl 2:5-28. [PMID: 32638537 DOI: 10.1111/codi.15140] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
AIM The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.
Collapse
Affiliation(s)
- J K Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - G A Binda
- Colorectal Surgery, BioMedical Institute, Genova, Italy
| | - G Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Biondo
- Department of General and Digestive Surgery - Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Chabok
- Colorectal Unit, Department of Surgery, Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S T van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Johanssen
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - W Kruis
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - D Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Post
- Mannheim Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - F Ris
- Division of Visceral Surgery, Geneva University hospitals and Medical School, Geneva, Switzerland
| | - T A Rockall
- Minimal Access Therapy Training Unit (mattu), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - A Samuelsson
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.,Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University Hospital of Varese, University of Insubria, Varese, Italy
| | - D Tartaglia
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - A Thorisson
- Department of Radiology, Västmanland's Hospital Västerås, Västerås, Sweden.,Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, Västerås, Sweden
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
| | - W Bemelman
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| |
Collapse
|
29
|
Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
30
|
Abstract
BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).
Collapse
|
31
|
A Brief Review of Nutraceutical Ingredients in Gastrointestinal Disorders: Evidence and Suggestions. Int J Mol Sci 2020; 21:ijms21051822. [PMID: 32155799 PMCID: PMC7084955 DOI: 10.3390/ijms21051822] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/12/2022] Open
Abstract
The dietary effect on gut health has long been recognized through the empirical practice of soothing gastric discomfort with certain types of food, and recently the correlation between specific diets with lower incidences of several gastrointestinal diseases has been revealed. Ingredients from those considered beneficial foods have been isolated and studied, and some of them have already been put into the supplement market. In this review, we focus on latest studies of these food-derived ingredients for their proposed preventive and therapeutic roles in gastrointestinal disorders, with the attempt of drawing evidence-based suggestions on consuming these products.
Collapse
|
32
|
Meyer J, Caruso A, Roos E, Balaphas A, Toso C, Poletti PA, Ris F, Buchs NC. The clinical significance of extraluminal air in Hinchey 1a diverticulitis: results from a retrospective cohort study with 10-year follow-up. Int J Colorectal Dis 2019; 34:2053-2058. [PMID: 31701220 DOI: 10.1007/s00384-019-03424-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Some patients with uncomplicated diverticulitis have extraluminal air. Our objective was to determine if patients with Hinchey 1a diverticulitis and isolated extraluminal air present more severe episode than patients without extraluminal air. METHODS The present study is a monocentric observational retrospective cohort study. Computed tomographies of patients with diagnosed uncomplicated diverticulitis were retrospectively reviewed from the 01 January 2005 to the 31 December 2009. The presence of extraluminal air was determined. Leukocyte count, CRP value, and length of hospitalization were extracted from the patients' files. The follow-up period was from the time of diagnosis to the 15th of March 2019, the latest. Follow-up was censored for death and sigmoidectomy. Recurrence and emergency sigmoidectomy were documented during the follow-up period. The study was performed according to the STROBE guideline. RESULTS Three hundred and one patients with an episode of Hinchey 1a diverticulitis were included. Extraluminal air was present in 56 patients (18.60%). Leukocyte count (12.4 ± 4.1(G/l) versus 10.7 ± 3.5(G/l), p = 0.05), CRP value (156.9 ± 95.1(mg/l) versus 89.9 ± 74.8(mg/l), p < 0.001), and length of hospital stay (10.9 ± 5.5(days) versus 8.4 ± 3.6(days), p < 0.001) were significantly higher in patients with extraluminal air than in patients without extraluminal air. Seventy-two patients (23.92%) presented a recurrence during the follow-up period. Survival estimates did not differ between patients with or without extraluminal air (p = 0.717). Eleven patients (3.65%) required emergency surgery during the follow-up period. Patients with extraluminal air had shorter emergency surgery-free survival than patients without extraluminal air (p < 0.05). CONCLUSION The presence of extraluminal air in Hinchey 1a diverticulitis indicates a more severe episode, with higher inflammation parameters at admission, longer length of stay, and an increased risk for emergency sigmoidectomy.
Collapse
Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland.
| | - Anna Caruso
- Division of Radiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Elin Roos
- Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Pierre-Alexandre Poletti
- Division of Radiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| | - Nicolas C Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland
| |
Collapse
|
33
|
Thorisson A, Nikberg M, Andreasson K, Smedh K, Chabok A. Non-operative management of perforated diverticulitis with extraluminal or free air - a retrospective single center cohort study. Scand J Gastroenterol 2019; 53:1298-1303. [PMID: 30353758 DOI: 10.1080/00365521.2018.1520291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of this study was to describe patient characteristics and results of non-operative management for patients presenting with computed tomography (CT) verified perforated diverticulitis with extraluminal or free air. METHODS All patients treated for diverticulitis (ICD-10: K-57) during 2010-2014 were identified and medical records were reviewed. Re-evaluations of CT examinations for all patients with complicated disease according to medical records were performed. All patients diagnosed with perforated diverticulitis and extraluminal or free air on re-evaluation were included and characteristics of patients having immediate surgery and those whom non-operative management was attempted are described. RESULTS Of 141 patients with perforated diverticulitis according to medical records, 136 were confirmed on CT re-evaluation. Emergency surgical intervention within 24 h of admission was performed in 29 (21%) patients. Non-operative management with iv antibiotics was attempted for 107 patients and was successful in 101 (94%). The 30-day mortality rate was 2%. The presence of a simultaneous abscess was higher for patients with failure of non-operative management compared with those that were successfully managed non-operatively (67% compared to 17%, p = .013). Eleven out of thirty-two patients (34%) with free air were successfully managed conservatively. Patients that were operated within 24 h from admission were more commonly on immunosuppressive therapy, had more commonly free intraperitoneal air and free fluid in the peritoneal cavity. CONCLUSIONS Non-operative management is successful in the majority of patients with CT-verified perforated diverticulitis with extraluminal air, and also in one-third of those with free air in the peritoneal cavity.
Collapse
Affiliation(s)
- A Thorisson
- a Department of Radiology , Västmanlands Hospital Västerås , Sweden.,c Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås , Sweden
| | - M Nikberg
- b Colorectal Unit, Department of Surgery , Västmanlands Hospital Västerås , Sweden.,c Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås , Sweden
| | - K Andreasson
- b Colorectal Unit, Department of Surgery , Västmanlands Hospital Västerås , Sweden.,c Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås , Sweden
| | - K Smedh
- b Colorectal Unit, Department of Surgery , Västmanlands Hospital Västerås , Sweden.,c Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås , Sweden
| | - A Chabok
- b Colorectal Unit, Department of Surgery , Västmanlands Hospital Västerås , Sweden.,c Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås , Sweden
| |
Collapse
|
34
|
Bolkenstein HE, van de Wall BJ, Consten EC, van der Palen J, Broeders IA, Draaisma WA. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol 2019; 53:1291-1297. [PMID: 30394135 DOI: 10.1080/00365521.2018.1517188] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Most diverticulitis patients (80%) who are referred to secondary care have uncomplicated diverticulitis (UD) which is a self-limiting disease and can be treated at home. The aim of this study is to develop a diagnostic model that can safely rule out complicated diverticulitis (CD) based on clinical and laboratory parameters to reduce unnecessary referrals. METHODS A retrospective cross-sectional study was performed including all patients who presented at the emergency department with CT-proven diverticulitis. Patient characteristics, clinical signs and laboratory parameters were collected. CD was defined as > Hinchey 1A. Multivariable logistic regression analyses were used to quantify which (combination of) variables were independently related to the presence or absence of CD. A diagnostic prediction model was developed and validated to rule out CD. RESULTS A total of 943 patients were included of whom 172 (18%) had CD. The dataset was randomly split into a derivation and validation set. The derivation dataset contained 475 patients of whom 82 (18%) patients had CD. Age, vomiting, generalized abdominal pain, change in bowel habit, abdominal guarding, C-reactive protein and leucocytosis were univariably related to CD. The final validated diagnostic model included abdominal guarding, C-reactive protein and leucocytosis (AUC 0.79 (95% CI 0.73-0.84)). At a CD risk threshold of ≤7.5% this model had a negative predictive value of 96%. CONCLUSION This proposed prediction model can safely rule out complicated diverticulitis. Clinical practitioners could cautiously use this model to aid them in the decision whether or not to subject patients to further secondary care diagnostics or treatment.
Collapse
Affiliation(s)
| | | | - Esther Cj Consten
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,c Department of Surgery , Meander Medical Centre , Amersfoort , The Netherlands
| | - Job van der Palen
- d Department of Research Methodology, Measurement & Data Analysis , University of Twente , Enschede , The Netherlands
| | - Ivo Amj Broeders
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,e Department of Surgery , Meander Medical Centre , Amersfoort , The Netherlands
| | - Werner A Draaisma
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,f Department of Surgery , Jeroen Bosch Hospital , 's-Hertogenbosch , The Netherlands
| |
Collapse
|
35
|
Ayoubi S, Chen M, Ravindran P, Gibson K. Ischio-anal abscess as a first presentation of complicated diverticular disease. ANZ J Surg 2019; 90:169-171. [PMID: 30790412 DOI: 10.1111/ans.15042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/20/2018] [Accepted: 12/04/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Salah Ayoubi
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Michelle Chen
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Praveen Ravindran
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, Western Sydney University, Sydney, New South Wales, Australia.,Department of Biomedical Engineering and Neuromorphic Systems (BENS), The MARCS Institute for Brain, Behaviour and Development, Sydney, New South Wales, Australia
| | - Katherine Gibson
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia.,Department of Surgery, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
36
|
Ditzel M, Vennix S, Menon AG, Verbeek PC, Bemelman WA, Lange JF. Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up. Dig Surg 2019; 36:129-136. [PMID: 29428950 PMCID: PMC6482984 DOI: 10.1159/000486868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection. AIMS The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis. METHODS During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years. RESULTS Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters. CONCLUSION This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.
Collapse
Affiliation(s)
- Max Ditzel
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands,Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands,*Max Ditzel, MD, Department of Surgery, Academic Medical Center, Diezestraat 8-II, NL–1078 JP Amsterdam (The Netherlands), E-Mail
| | - Sandra Vennix
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Anand G. Menon
- Department of Surgery, Erasmus Medical Center, Havenziekenhuis, Rotterdam, The Netherlands
| | - Paul C.M. Verbeek
- Department of Surgery, Flevohospital Almere, Almere, The Netherlands
| | - Willem A. Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Johan F. Lange
- Department of Surgery, Erasmus Medical Center, Havenziekenhuis, Rotterdam, The Netherlands,Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
37
|
Di Sabatino A, Lenti MV, Cammalleri L, Corazza GR, Pilotto A. Frailty and the gut. Dig Liver Dis 2018; 50:533-541. [PMID: 29628357 DOI: 10.1016/j.dld.2018.03.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/02/2018] [Accepted: 03/08/2018] [Indexed: 02/08/2023]
Abstract
Frailty, which is a syndrome that encompasses losses in physical, psychological and social domains, is responsible for enhanced vulnerability to endogenous and/or exogenous stressors. Frailty is a public health problem for an ageing society; however, it is poorly understood and often under-recognised in clinical settings. In particular, the impact of frailty on either intestinal functions, i.e. immune response, permeability, and absorption, or gut microbiota composition is as yet mostly unexplored. A better comprehension of the intestinal dysfunction occurring in the elderly would help in clarifying the mechanisms predisposing frail patients to a higher risk of infectious or inflammatory events. Moreover, recent evidence suggests that senescence-induced perturbations of the gut-brain axis are involved in the neuroinflammation process, thus raising the hypothesis that preserving gut permeability and preventing frailty-related changes in the microbiota composition might reduce the susceptibility to develop neurodegenerative disorders. In this review, we highlight the current insights concerning the relationship between frailty, intestinal functions, microbiota, and gut-brain axis.
Collapse
Affiliation(s)
- Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Lisa Cammalleri
- Department of Geriatric Care, OrthoGeriatrics and Rehabilitation, Frailty Area, Galliera Hospital, Genova, Italy
| | - Gino Roberto Corazza
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Alberto Pilotto
- Department of Geriatric Care, OrthoGeriatrics and Rehabilitation, Frailty Area, Galliera Hospital, Genova, Italy.
| |
Collapse
|
38
|
Yücesoy AN. Letter to the editor on "risk factors for complicated diverticulitis: systematic review and meta-analysis". What is the place of lateral internal partial sphincterotomy in the recurrent colonic diverticulitis treatment? Int J Colorectal Dis 2018; 33:111. [PMID: 29052753 DOI: 10.1007/s00384-017-2920-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Ali Naki Yücesoy
- General Surgery Department, Batı Bahat Hospital, Atatürk mah. İkitelli cad. No:135 K.Çekmece, Istanbul, Turkey.
| |
Collapse
|
39
|
Zhang J, Zhao T, Long S, Liu X, Yu H. Risk factors for postoperative infection in Chinese lung cancer patients: A meta-analysis. J Evid Based Med 2017; 10:255-262. [PMID: 28884946 DOI: 10.1111/jebm.12276] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/08/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of this study was to identify risk factors for postoperative infection in Chinese lung cancer patients. METHODS A comprehensive search was performed in PubMed, EMbase, CNKI, and WanFang Data databases to identify studies investigating risk factors for postoperative infection in Chinese lung cancer patients. Meta-analysis was performed by using Revman 5.2 software. RESULTS A total of 12 studies were included. The results of meta-analysis showed that old age, male gender, diabetes, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer time of surgery procedure were associated with increased risk of postoperative infection. In addition, prophylactic antibiotic was associated with decreased risk of postoperative infection. CONCLUSION The current meta-analysis suggests that the old age, male gender, diabetes mellitus, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer of surgery time are risk factors for postoperative infection in Chinese lung cancer patients. Due to the limited quality and quantity of included studies, more high-quality studies are needed to verify the above results.
Collapse
Affiliation(s)
- Jie Zhang
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Taiqiang Zhao
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Shanshan Long
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Xin Liu
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Hua Yu
- Department of Laboratory Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| |
Collapse
|