Validation of the German Classification of Diverticular Disease (VADIS)-a prospective bicentric observational study

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

CITATION FORMAT

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

Is there a link between appendicitis and the risk of diverticular disease?: a large German cohort study

PURPOSE

Appendicitis, characterized by inflammation of the vermiform appendix, is a common abdominal emergency necessitating appendectomy. Recent evidence suggests a potential link between appendicitis and subsequent diverticular disease, yet population-based studies investigating this association are limited.

METHODS

Utilizing the Disease Analyzer database encompassing data from over 1000 primary care practices in Germany, we conducted a retrospective cohort study. We included 25,379 adults diagnosed with appendicitis and an equal number of matched controls without appendicitis. The incidence of diverticular disease over a 10-year follow-up period was compared between the two cohorts. Cox regression analysis was performed to assess the association between appendicitis and diverticular disease, adjusting for potential confounders.

RESULTS

Our findings revealed a significant association between appendicitis and subsequent diverticular disease (HR: 1.76; 95% CI: 1.57-1.97), with an increased risk observed across all age groups. Notably, this association was stronger in men (HR: 2.00; 95% CI: 1.68-2.37) than in women (HR: 1.58; 95% CI: 1.36-1.84). The cumulative 10-year incidence of diverticular disease was higher in patients with appendicitis (6.5%) compared to those without (3.6%). Additionally, we observed a clear age-dependent increase in the incidence of diverticular disease.

CONCLUSION

This large-scale population-based study provides valuable insights into the interaction between appendicitis and diverticular disease. The study underscores the need for further research elucidating the underlying mechanisms linking appendicitis to diverticular disease. Probiotics emerge as a potential therapeutic avenue warranting exploration in the management of both conditions. These findings have important implications for clinical practice, highlighting the importance of considering appendicitis as a potential risk factor for diverticular disease, particularly in men. Further investigation is warranted to validate these findings and explore potential therapeutic interventions targeting the shared pathophysiological pathways underlying both conditions.

Inpatient treatment of acute diverticulitis between 2010 and 2021 - A German nationwide study about long-term trends and effects of the SARS-CoV-2 pandemic

AIM

The aims of this study were to analyse all hospitalizations for acute diverticulitis in Germany from 2010 to 2021 and to assess the effects of the first 2 years of the SARS-CoV-2 pandemic on hospitalizations for acute diverticulitis.

METHOD

Using data from the German Federal Statistical Office, we analysed fully anonymized healthcare data of hospitalizations and treatment regimens with acute diverticulitis as the main diagnosis between 2010 and 2021. Logistic regression analyses for in-hospital mortality were performed.

RESULTS

A total of 608,162 hospitalizations were included. While the number of hospitalizations constantly increased until 2019 (+52.4%), a relative decrease of 10.1% was observed between 2019 and 2020, followed by stable numbers of hospitalizations in 2021 (+1.1% compared with 2020). In-hospital mortality showed a relative decrease of 33.2% until 2019 and thereafter a relative increase of 26.9% in 2020 and of 7.5% in 2021. A 21.6% and a 19.3% drop in hospitalizations was observed during the first and second waves of the SARS-CoV-2 pandemic, mostly affecting hospitalizations for uncomplicated diverticulitis, with a corresponding 11.6% and 16.8% increase in admissions for complicated diverticulitis. Multivariable logistic regression analyses showed significantly higher in-hospital mortality for hospitalizations in which surgery (OR = 2.76) and CT (OR = 1.32) were given, as well as lower mortality for women (OR = 0.88), whereas percutaneous drainage was not associated with higher in-hospital mortality compared with conservative treatment (OR = 0.71).

CONCLUSION

This study points out the long-term trends in inpatient treatment for acute diverticulitis and the in-hospital mortality risk factors of patients hospitalized for acute diverticulitis in a large nationwide cohort, as well as changes in these trends and factors resulting from the SARS-CoV-2 pandemic. These changes might be attributable to delayed diagnosis and thus more severe stages of disease as a result of containment measures.

Identification of diverticular disease in Swedish healthcare registers: a validation study

PURPOSE

The Swedish National Patient Register (SNPR) is frequently used in studies of colonic diverticular disease (DD). Despite this, the validity of the coding for this specific disease in the register has not been studied.

METHODS

From SNPR, 650 admissions were randomly identified encoded with ICD 10, K572-K579. From the years 2002 and 2010, 323 and 327 patients respectively were included in the validation study. Patients were excluded prior to, or up to 2 years after a diagnosis with IBD, Celiac disease, IBS, all forms of colorectal cancer (primary and secondary), and anal cancer. Medical records were collected and data on clinical findings with assessments, X-ray examinations, endoscopies and laboratory results were reviewed. The basis of coding was compared with internationally accepted definitions for colonic diverticular disease. Positive predictive values (PPV) were calculated.

RESULTS

The overall PPV for all diagnoses and both years was 95% (95% CI: 93-96). The PPV for the year 2010 was slightly higher 98% (95% CI: 95-99) than in the year 2002, 91% (95% CI: (87-94) which may be due to the increasing use of computed tomography (CT).

CONCLUSION

The validity of DD in SNPR is high, making the SNPR a good source for population-based studies on DD.

Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients

OBJECTIVE

Weighing the perioperative risk of elective sigmoidectomy is done regardless of the specific diverticulitis classification. The aim of this study is to evaluate surgical outcomes according to the classification grade and the indication.

METHODS

All patients who underwent elective colonic resection for diverticulitis during the ten-year study period were included. They were divided into two groups: relative surgery indication (RSI) and absolute surgery indication (ASI). RSI included microabscess and recurrent uncomplicated disease. ASI included macroabscess and recurrent complicated disease. Propensity score-matching (PSM, 1:1) was performed.

RESULTS

585 patients fulfilled criteria for RSI and 318 patients fulfilled criteria for ASI. In the univariate analysis, RSI patients were younger (62 vs. 67.7 years, p < 0.001), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p < 0.001), were less immunosuppressed (3.4% vs. 6.9%, p = 0.021) and suffered less often from coronary heart disease (3.8% vs. 7.2%, p = 0.025). After PSM, 318 RSI vs. 318 ASI patients were selected; baseline characteristics results were comparable. The proportion of planned laparoscopic resection was 93% in RSI versus 75% in ASI (p < 0.001), and the conversion rate to open surgery for laparoscopic resection was 5.0% and 13.8% in RSI versus ASI, respectively (p < 0.001). Major morbidity (Clavien/Dindo ≥ IIIb) occurred less frequently in RSI (3.77% vs. 10%, p = 0.003). A defunctioning stoma was formed in 0.9% and 11.0% in RSI vs ASI, respectively (p < 0.001).

CONCLUSION

The lower risk for postoperative morbidity, the higher chance for a laparoscopic resection and the decreased rate of stoma formation are attributed to patients with recurrent uncomplicated diverticulitis or diverticulitis including a microabscess as compared to patients with complicated diverticulitis or diverticulitis and a macroabscess, and this applies even after PSM.

Health-Related Quality of Life and Stress-Related Disorders in Patients with Complicated Diverticular Disease under Conservative Management

Diverticular disease is a common gastrointestinal disorder with increasing prevalence in advanced age. This study aimed to investigate the impact of age and complexity of diverticulitis on health-related quality of life (HRQoL) and stress-related disorders. A cross-sectional study was conducted on 180 patients, including adults (18-64 years) with complicated diverticular disease, the elderly (≥65 years) with complicated diverticular disease, and a control group with uncomplicated symptomatic diverticular disease. HRQoL and stress-related disorders were assessed using the SF-36, GIQLI, HADS, and PHQ-9 questionnaires at baseline and six months after the initial episode of diverticulitis. At diagnosis, the adult group had significantly lower mean physical and mental scores compared with the elderly and control groups (p < 0.001). At the 6-month follow-up, the mean physical score increased for all groups, but the difference between adults and the elderly remained significant (p = 0.028). The adult group had a significantly lower mean GIQLI score at diagnosis compared with the elderly and control groups (p < 0.001), although after 6 months it increased and the difference became insignificant. Anxiety scores at diagnosis were significantly higher in the adult group compared with the control group (p = 0.009). The complexity of diverticulitis and age significantly impacted HRQoL at diagnosis, with adults having lower physical and mental scores compared with elderly patients and controls. Although improvements were observed after 6 months, the difference between adults and the elderly remained significant for physical HRQoL scores. This highlights the need for tailored management strategies and psychosocial support to optimize patient outcomes across age groups and diverticulitis complexity.

Early elective versus elective sigmoid resection in diverticular disease: not only timing matters-a single institutional retrospective review of 133 patients

Purpose

The optimal timing of elective surgery in patients with the colonic diverticular disease remains controversial. We aimed to analyze the timing of sigmoidectomy in patients with diverticular disease and its influence on postoperative course with respect to the classification of diverticular disease (CDD).

Methods

Patients who underwent elective laparoscopic sigmoidectomy were retrospectively enrolled and subdivided into two groups based on the time interval between the last attack and surgery: group A, early elective (≤ 6 weeks), and group B, elective (> 6 weeks). Multivariate regression models were used to identify factors which predict conversion to laparotomy, postoperative course, and length of hospital stay.

Results

A total of 133 patients (group A (n = 88), group B (n = 45)) were included. Basic demographic data did not differ between groups except for a higher rate of diabetes in group B (p = 0.009). The conversion rate was significantly higher in group A in comparison to group B (group A vs. group B: n = 23 (26.1%) vs. n = 3 (6.7%), p = 0.007). Logistic regression analysis revealed the timing of surgery and CDD stage as significant predictors for intraoperative conversion. Moreover, the postoperative course was influenced by high age as well as intraoperative conversion and length of hospital stay by conversion, preoperative CRP levels, and elective surgery.

Conclusions

Both, timing of surgery and the disease stage, influence the conversion rates in laparoscopic sigmoidectomy for diverticular disease. Accordingly, patients with complicated acute or chronic sigmoid diverticulitis should be operated in the inflammation-free interval.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02464-1.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Value of high-field magnetic resonance imaging for diagnosis and classification of acute colonic diverticulitis

OBJECTIVES

Due to limited and outdated literature, the role of magnetic resonance imaging (MRI) in the diagnostic work-up of acute colonic diverticulitis (ACD) is still under debate. The purpose of this study was to compare the performance of modern high-field MRI and multidetector computed tomography (MDCT) in the diagnosis and classification of ACD.

METHODS

In our prospective study 24 emergency patients with the clinical diagnosis of ACD received MDCT and high-field MRI. Imaging features of ACD were assessed and categorized according to the classification of diverticular disease (CDD) by three independent readers. Results were matched with the final clinical report.

RESULTS

MRI with a specialized examination protocol clearly depicted all relevant findings of ACD. Statistical analysis resulted in an almost perfect strength of agreement between CT and MRI across all readers for the final CDD category (κ = 0.94) and the stage-related image features (κ = 0.98). Moderate agreement was seen for the detection of micro-abscesses (κ = 0.78), with a slight advantage for MRI.

CONCLUSION

Modern high-field MRI is fully comparable to MDCT in the assessment of ACD and has the potential to serve as a first-line imaging tool.

[Indications for surgical treatment of diverticular disease]

BACKGROUND

The correct medical indications are the fundamental decision process for the surgical treatment and ensuring the quality.

OBJECTIVE

Description of the indications for surgical treatment of the various types of diverticular disease according to the current level of evidence.

MATERIAL AND METHODS

The narrative review is based on current national and international guidelines and a selective literature search.

RESULTS

There are basically three main indications for resection of the sigmoid colon. 1) Prophylactic for avoidance of complications after successful conservative treatment of acute complicated diverticulitis with macroabscess formation and high risk of recurrence (classification of diverticular disease, CDD, type 2b). 2) In patients with persistent symptoms and impaired quality of life resection of the sigmoid colon of various types (CDD types 1-3) can effectively enable a significant improvement in the quality of life and is therefore to be recommended in cases of individually acceptable perioperative risks. 3) Indications for urgent resection of the sigmoid colon are present for free perforation or failure of conservative treatment.

CONCLUSION

The indications for surgery should be defined by the type of diverticular disease, the aim of surgical treatment, the evaluation of the efficacy of surgical treatment in comparison to conservative treatment and an individual appraisal of the risks.

To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon

PURPOSE

 To assess the value of the administration of positive rectal contrast at CT in patients referred for suspected diverticular disease (DD) of the colon.

MATERIALS AND METHODS

 460 patients (253 male, 207 female; median age 62 years; interquartile range 24) with clinical suspicion of DD of the colon were included in this retrospective IRB-approved study. CT was performed with i. v. contrast only (n = 328, group M1), i. v. + positive rectal contrast (n = 82, group M2), neither i. v. nor rectal contrast (n = 32, group S1), or positive rectal contrast only (n = 19, group S2). Two readers in consensus evaluated all CT datasets concerning diagnosis of DD (yes/no) and categorized findings (classification of diverticular disease (CDD)). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for the diagnosis of DD were calculated for all groups, using either clinical follow-up (n = 335) or intraoperative findings (n = 125) as the reference standard. In patients undergoing surgery, radiological staging of DD was correlated with the histopathology (weighted Cohen-k).

RESULTS

 224 patients (48.7 %) were diagnosed with DD. The sensitivity, specificity, PPV, and NPV were as follows. Group M1 / M2: 92 %/92 %, 97 %/94 %, 96 %/96 %, 94 %/89 %, respectively; group S1 / S2: 94 %/86 %, 93 %/80 %, 94 %/92 %, 93 %/67 %, respectively. Radiological staging and histopathology correlated substantially in all groups (k = 0.748-0.861).

CONCLUSION

 Abdominal CT had a high sensitivity and specificity for the diagnosis of DD. Disease staging correlated well with the findings at surgery. Additional positive rectal contrast administration did not have a significant advantage and may therefore be omitted in patients with suspected DD.

KEY POINTS

· CT has a high sensitivity and specificity for diagnosis of DD.. · CT staging using the CDD algorithm correlates very well with surgery.. · Positive rectal contrast administration does not improve diagnosis and radiological staging..

CITATION FORMAT

· Meyer S, Schmidbauer M, Wacker FK et al. To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon. Fortschr Röntgenstr 2021; 193: 804 - 812.