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

Minimally invasive versus open surgery for colonic diverticular disease: a nationwide analysis of German hospital data

BACKGROUND

This study aims to evaluate the current rates and outcomes of minimally invasive versus open surgery for colonic diverticular disease in Germany, using a nationwide dataset.

METHODS

We analyzed data from 36 hospitals, encompassing approximately 1.25 million hospitalizations from 1 January 2019 to 31 December 2023. Patients aged 18 years and older with colonic diverticular disease (International Classification of Diseases, Tenth Revision (ICD-10): K57.2 and K57.3) who underwent surgical treatment were included. Surgeries were classified as open or minimally invasive (laparoscopic or robotic). Outcomes such as in-hospital mortality, complications, and length of stay were assessed using multivariable logistic and linear regression models.

RESULTS

Out of 1670 patients who underwent surgery for colonic diverticular disease, 63.2% had perforation and abscess. The rate of minimally invasive surgery increased from 34.6% in 2019 to 52.9% in 2023 for complicated cases and from 67.8% to 86.2% for uncomplicated cases. Open surgery was associated with higher in-hospital mortality (odds ratio (OR): 7.41; 95% CI: 2.86-19.21) and complications compared with minimally invasive surgery. The length of hospital stay was significantly longer for open surgery patients, with an increase of 4.6 days for those with perforation and abscess and 5.0 days for those without.

CONCLUSIONS

Minimally invasive surgery for colonic diverticular disease is increasingly preferred in Germany, especially for uncomplicated cases. However, open surgery remains common for complicated cases, but is associated with higher mortality, more complications, and longer hospital stays.

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.

A New Nomogram-Based Prediction Model for Postoperative Outcome after Sigmoid Resection for Diverticular Disease

Background and Objectives: Sigmoid resection still bears a considerable risk of complications. The primary aim was to evaluate and incorporate influencing factors of adverse perioperative outcomes following sigmoid resection into a nomogram-based prediction model. Materials and Methods: Patients from a prospectively maintained database (2004-2022) who underwent either elective or emergency sigmoidectomy for diverticular disease were enrolled. A multivariate logistic regression model was constructed to identify patient-specific, disease-related, or surgical factors and preoperative laboratory results that may predict postoperative outcome. Results: Overall morbidity and mortality rates were 41.3% and 3.55%, respectively, in 282 included patients. Logistic regression analysis revealed preoperative hemoglobin levels (p = 0.042), ASA classification (p = 0.040), type of surgical access (p = 0.014), and operative time (p = 0.049) as significant predictors of an eventful postoperative course and enabled the establishment of a dynamic nomogram. Postoperative length of hospital stay was influenced by low preoperative hemoglobin (p = 0.018), ASA class 4 (p = 0.002), immunosuppression (p = 0.010), emergency intervention (p = 0.024), and operative time (p = 0.010). Conclusions: A nomogram-based scoring tool will help stratify risk and reduce preventable complications.

The optimal timing of elective surgery in sigmoid diverticular disease: a meta-analysis

PURPOSE

The aim of this meta-analysis was to investigate the optimal time point of elective sigmoidectomy regarding the intraoperative and postoperative course in diverticular disease.

METHODS

A comprehensive literature research was conducted for studies comparing the operative outcome of early elective (EE) versus delayed elective (DE) minimally invasive sigmoidectomy in patients with acute or recurrent diverticular disease. Subsequently, data from eligible studies were extracted, qualitatively assessed, and entered into a meta-analysis. By using random effect models, the pooled hazard ratio of outcomes of interest was calculated.

RESULTS

Eleven observational studies with a total of 2096 patients were included (EE group n = 828, DE group n = 1268). Early elective sigmoidectomy was associated with a significantly higher conversion rate as the primary outcome in comparison to the delayed elective group (OR 2.48, 95% CI 1.5427-4.0019, p = 0.0002). Of the secondary outcomes analyzed only operative time (SMD 0.14, 95% CI 0.0020-0.2701, p = 0.0466) and time of first postoperative bowel movement (SMD 0.57, 95% CI 0.1202-1.0233, p = 0.0131) were significant in favor of the delayed elective approach.

CONCLUSIONS

Delayed elective sigmoid resection demonstrates benefit in terms of reduced conversion rates and shortened operative time as opposed to an early approach. Conversely, operative morbidities seem to be unaffected by the timing of surgery. However, a final and robust conclusion based on the included observational cohort studies must be cautiously made. We therefore highly advocate larger randomized controlled trials with homogenous study protocols.

Surgical management in immunosuppressed patients with sigmoid diverticulitis, still a challenge: a single-center observational study

PURPOSE

The question of whether immunosuppressed (IS) patients should be offered elective sigmoidectomy following a single episode of diverticulitis is controversial. We intended to examine the perioperative outcome of IS and immunocompetent (IC) patients after sigmoid resection.

METHODS

A single institutional cohort study was conducted, including all surgically treated patients with sigmoid diverticulitis between 2004 and 2021. IS and IC patients were further subdivided into emergency and elective cases. Morbidity and mortality in both groups and factors influencing surgical outcome were examined using uni- and multivariate regression analyses.

RESULTS

A total of 281 patients were included in the final analysis. Emergency surgery was performed on 98 patients while 183 patients underwent elective sigmoid resection. Emergency sigmoidectomy demonstrates significantly higher morbidity and mortality rates in IS patients as compared to IC patients (81.81% vs. 42.1%; p = 0.001, respectively 27.27% vs. 3.94%; p = 0.004), while major morbidity and mortality was similar in both groups in the elective setting (IS: 23.52% vs. IC: 13.85%; p = 0.488, respectively IS: 5.88% vs. IC: 0%; p = 1). On multivariate regression analysis for major postoperative morbidity, ASA score [OR 1.837; (95% CI 1.166-2.894); p = 0.009] and emergency surgery under immunosuppression [OR 3.065; (95% CI 1.128-8.326); p = 0.028] were significant. In-hospital mortality was significantly related to age [OR 1.139; (95% CI 1.012-1.282); p = 0.031], preoperative CRP count [OR 1.137; (95% CI 1.028-1.259); p = 0.013], and immunosuppression [OR 35.246; (95% CI 1.923-646.176), p = 0.016] on multivariate analysis.

CONCLUSIONS

Elective surgery for sigmoid diverticulitis in immunocompromised patients demonstrates higher efficacy and safety when compared to sigmoid resection in the emergency setting.