Surgical resection does not avoid the risk of diverticulitis recurrence-a systematic review of risk factors

Acute diverticulitis: beyond the diagnosis: predictive role of CT in assessing risk of recurrence and clinical implications in non-operative management of acute diverticulitis

PURPOSE

The aim of the study is to identify CT findings that are predictive of recurrence of acute uncomplicated colonic diverticulitis, to better risk-stratify these patients for whom guidelines recommend a conservative outpatient treatment and to determine the appropriate management with an improvement of health costs.

MATERIALS AND METHODS

Over the past year, 33 patients enrolled in an outpatient integrated care pathway (PDTA) for uncomplicated acute diverticulitis with 1-year follow-up period, without recurrence, and 33 patients referred to Emergency Department for a recurrent acute diverticulitis were included. Images of admission CT were reviewed by two radiologists and the imaging features were analyzed and compared with Chi-square and Student t tests. Univariate and multivariate Cox regression models were employed to identify parameters that significantly predicted recurrence in 1-year follow-up period and establish cutoff and recurrence-free rates. The maximally selected rank statistics (MSRS) were used to identify the optimal wall thickening cutoff for the prediction of recurrence.

RESULTS

Patients with recurrence showed a greater mean parietal thickness compared to the group without recurrence (16 mm vs. 11.5 mm; HR 1.25, p < 0.001) and more evidence of grade 4 of peridiverticular inflammation (40% vs. 12%, p = 0.009, HR 3.44). 12-month recurrence-free rates progressively decrease with increasing thickness and inflammation. In multivariate analysis, only parietal thickness maintained its predictive power with an optimal cutpoint > 15 mm that causes a sixfold increased risk of recurrence (HR 6.22; 95% CI, 3.05-12.67; p < 0.001). Beyond thickness and peridiverticular inflammation, predictive value of early recurrence within 90 days from the 1st episode resulted also an Hinchey Ib on admission CT.

CONCLUSIONS

The maximum wall thickening and the grade of peridiverticular inflammation can be considered as predictive factors of recurrence and may be helpful in selecting patients for a tailored treatment to prevent the risk of recurrence.

Novel patch biomaterial treatment for colon diverticulosis in swine model

Current leading managements for diverticular disease cannot prevent the recurrence of diverticulitis, bleeding and/or other complications. There is an immediate need for developing new minimal invasive therapeutic strategies to prevent and treat this disease. Through a biomechanical analysis of porcine colon with diverticular lesions, we proposed a novel adhesive patch concept aiming at mechanical reconstruction of the diseased colon wall. This study aims to evaluate the surgical feasibility (safety and efficacy) of pulmonary visceral pleura (PVP) patch therapy using a pig model of diverticulosis. Six female Yucatan miniature pigs underwent collagenase injection (CI) for the development of diverticular lesions. The lesions in each animal either received patch implantation (treated group, n = 40 for 6 pigs) or left intact (untreated group, n = 44 for 6 pigs). The normal colonic wall in each animal received patch implantation at two spots to serve as control (n = 12 for 6 pigs). After 3 months of observation, the performance and safety of the patch treatment were evaluated through macroscopic and histological examination. We found that 95% of pouch-like herniation of the mucosa was prevented from the colon wall with the treatment. The pouch diameter was significantly reduced in the treated group as compared to the untreated group (p < 0.001). The patch application caused a significant increase in the levels of collagen of the colon tissue as compared to the untreated and control groups (p < 0.001). No difference was found in the lymphocyte and macrophage inflammatory infiltrate between the groups. Our results suggest that patch treatment efficiently inhibits the diverticular pouch deformation and promotes the healing of the colon wall with a normal inflammatory response, which may minimize the risk of diverticulosis reoccurrence and complications over time.

Incidence of diverticulitis recurrence after sigmoid colectomy: a retrospective cohort study from a tertiary center and systematic review

INTRODUCTION

Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease.

METHODS

Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021).

RESULTS

One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years.

CONCLUSION

The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.

Recurrence of diverticulitis after prophylactic sigmoidectomy: an underestimated problem?

AIM

Several papers have been published about the risk of recurrence after an attack of diverticulitis treated conservatively. However, very few papers have been devoted to the risk of postoperative recurrence of diverticulitis (PRD) after prophylactic sigmoidectomy (PS). The aim of this work was to report the rate of PRD after PS and to assess possible risk factors for recurrence after surgery.

METHOD

All consecutive patients who underwent elective laparoscopic PS for diverticulitis between 2005 and 2019 were retrospectively included. PRD was assessed.

RESULTS

Three hundred and sixty four patients (199 men, mean age 54 ± 13 years) were included. Among these, 26 (7%) presented with 1.7 ± 1 (range 1-4) episodes of recurrence of diverticulitis after a mean delay of 44 ± 39 months (1 month-11 years) after surgery. Patients who presented with postoperative recurrence of diverticulitis were younger (46 ± 11 vs. 55 ± 13 years, p = 0.002) and more frequently had uncomplicated diverticulitis [15/26 (58%) vs. 97/338 (29%), p = 0.002] and more than two previous episodes before PS [17/26 (65%) vs. 132/338 (39%), p = 0.009] than patients without PRD. After multivariate analysis, two independent risk factors for PRD were identified: patients with more than two episodes before PS (OR = 3.3, 95% CI = 1.2-9, p = 0.005) and age < 50 years (OR = 4.5, 95% CI = 2-11, p = 0.001). If both factors were present, recurrence reached 18% (9/51).

CONCLUSION

Postoperative recurrence of diverticulitis is rare (7%) after PS for diverticulitis. Some patients (i.e. those with more than two episodes before PS and/or age <50 years) could be exposed to a higher risk of recurrence (up to 18%), making prophylactic surgery questionable in these patients.

Recurrent diverticulitis after elective surgery

PURPOSE

Elective sigmoid resection is proposed as a treatment for symptomatic diverticular disease for the possible improvement in quality of life achievable. Albeit encouraging results have been reported, recurrent diverticulitis is still a concern deeply affecting quality of life. The aim of this study is to determine the rate of recurrent diverticulitis after elective sigmoid resection and to look for possible perioperative risk factors.

METHODS

Patients who underwent elective resection for DD with at least a 3-year follow-up were included. Postoperative recurrence was defined as left-sided or lower abdominal pain, with CT scan-confirmed findings of diverticulitis.

RESULTS

Twenty of 232 (8.6%) patients developed CT-proven recurrent diverticulitis after elective surgery. All the 20 recurrent diverticulitis were uncomplicated and did not need surgery. Eighty-five percent of the recurrences occurred in patients with a preoperative diagnosis of uncomplicated DD, 70% in patients who had at least 4 episodes of diverticulitis, and 70% in patients with a history of diverticulitis extended to the descending colon. Univariate analysis showed that recurrence was associated with diverticulitis of the sigmoid and of the descending colon (p = 0.04), with a preoperative diagnosis of IBS (p = 0.04) and with a longer than 5 years diverticular disease (p = 0.03). Multivariate analysis was not able to determine risks factors for recurrence.

CONCLUSION

Our study showed that patients with a preoperative diagnosis of IBS, diverticulitis involving the descending colon, and a long-lasting disease are more likely to have recurrent diverticulitis. However, these variables could not be assumed as risk factors.

Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases

The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.

[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.