Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc. 2011;25:1121-1126. [PMID: 20872022 DOI: 10.1007/s00464-010-1327-0]

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.

Robotic surgery versus conventional laparoscopy in sigmoid colectomy for diverticular disease-a comparison of operative trauma and cost-effectiveness: retrospective, single-center analysis

PURPOSE

Robotic assisted surgery is an alternative, fast evolving technique for performing colorectal surgery. The primary aim of this single center analysis is to compare elective laparoscopic and robotic sigmoid colectomies for diverticular disease on the extent of operative trauma and the costs.

METHODS

Retrospective analysis from our prospective clinical database to identify all consecutive patients aged ≥ 18 years who underwent elective minimally invasive left sided colectomy for diverticular disease from January 2016 until December 2020 at our tertiary referral institution.

RESULTS

In total, 83 patients (31 female and 52 male) with sigmoid diverticulitis underwent elective minimally invasive sigmoid colectomy, of which 42 underwent conventional laparoscopic surgery (LS) and 41 robotic assisted surgery (RS). The mean C-reactive protein difference between the preoperative and postoperative value was significantly lower in the robotic assisted group (4,03 mg/dL) than in the laparoscopic group (7.32 mg/dL) (p = 0.030). Similarly, the robotic´s hemoglobin difference was significantly lower (p = 0.039). The first postoperative bowel movement in the LS group occurred after a mean of 2.19 days, later than after a mean of 1.63 days in the RS group (p = 0.011). An overview of overall charge revealed significantly lower total costs per operation and postoperative hospital stay for the robotic approach, 6058 € vs. 6142 € (p = 0,014) not including the acquisition and maintenance costs for both systems.

CONCLUSION

Robotic colon resection for diverticular disease is cost-effective and delivers reduced intraoperative trauma with significantly lower postoperative C-reactive protein and hemoglobin drift compared to conventional laparoscopy.

Management of Diverticulitis: A Review

Importance

Care of patients with diverticulitis is undergoing a paradigm shift. This narrative review summarizes the current evidence for left-sided uncomplicated and complicated diverticulitis. The latest pathophysiology, advances in diagnosis, and prevention strategies are also reviewed.

Observations

Treatment is moving to the outpatient setting, physicians are forgoing antibiotics for uncomplicated disease, and the decision for elective surgery for diverticulitis has become preference sensitive. Furthermore, the most current data guiding surgical management of diverticulitis include the adoption of new minimally invasive and robot-assisted techniques.

Conclusions and Relevance

This review provides an updated summary of the best practices in the management of diverticulitis to guide colorectal and general surgeons in their treatment of patients with this common disease.

Fragility of Statistically Significant Outcomes in Colonic Diverticular Disease Randomized Trials: A Systematic Review

BACKGROUND

The p value has been criticized as an oversimplified determination of whether a treatment effect exists. One alternative is the fragility index. It is a representation of the minimum number of nonevents that would need to be converted to events to increase the p value above 0.05.

OBJECTIVE

To determine the fragility index of randomized controlled trials assessing the efficacy of interventions for patients with diverticular disease since 2010 to assess the robustness of current evidence.

DESIGN

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to August 2022.

SETTINGS

Articles were eligible for inclusion if they were randomized trials conducted between 2010 and 2022 with parallel, superiority designs evaluating interventions in patients with diverticular disease. Only randomized trials with dichotomous primary outcomes with an associated p value of <0.05 were considered for inclusion.

PARTICIPANTS

Any surgical or medical intervention for patients with diverticular disease.

MAIN OUTCOME MEASURES

The fragility index was determined by adding events and subtracting nonevents from the groups with the smaller number of events. Events were added until the p value exceeded 0.05. The smallest number of events required was considered the fragility index.

RESULTS

After screening 1271 citations, 15 randomized trials met the inclusion criteria. Nine of the studies evaluated surgical interventions and 6 evaluated medical interventions. The mean number of patients randomly assigned and lost to follow-up per randomized controlled trial was 92 (SD 35.3) and 9 (SD 11.4), respectively. The median fragility index was 1 (range, 0-5). The fragility indices for the included studies did not correlate significantly with any study characteristics.

LIMITATIONS

Small sample, heterogeneity, and lack of inclusion of studies with continuous outcomes.

CONCLUSIONS

The randomized trials evaluating surgical and medical interventions for diverticular disease are not robust. Changing a single-outcome event in most studies was sufficient to make a statistically significant study finding not significant. See Video Abstract .

FRAGILIDAD DE LOS RESULTADOS ESTADSTICAMENTE SIGNIFICATIVOS EN ENSAYOS ALEATORIOS DE ENFERMEDAD DIVERTICULAR DEL COLON UNA REVISIN SISTEMTICA

ANTECEDENTES:El valor p ha sido criticado por una determinación demasiado simplificada de si existe un efecto del tratamiento. Una alternativa es el Índice de Fragilidad. Es una representación del número mínimo de no eventos que deberían convertirse en eventos para aumentar el valor p por encima de 0,05.OBJETIVO:Determinar el IF de ensayos controlados aleatorios que evalúan la eficacia de las intervenciones para pacientes con enfermedad diverticular desde 2010 para evaluar la solidez de la evidencia actual.FUENTES DE DATOS:Se realizaron búsquedas en MEDLINE, Embase y CENTRAL desde el inicio hasta agosto de 2022.SELECCIÓN DE ESTUDIOS:Los artículos eran elegibles para su inclusión si eran ensayos aleatorizados realizados entre 2010 y 2022 con diseños paralelos de superioridad que evaluaran intervenciones en pacientes con enfermedad diverticular. Sólo se consideraron para su inclusión los ensayos aleatorizados con resultados primarios dicotómicos con un valor de p asociado menor que 0,05.INTERVENCIÓNES:Cualquier intervención quirúrgica o médica para pacientes con enfermedad diverticular.PRINCIPALES MEDIDAS DE VALORACIÓN:El índice de fragilidad se determinó sumando eventos y restando no eventos de los grupos con el menor número de eventos. Se agregaron eventos hasta que el valor p superó 0,05. El menor número de eventos requeridos se consideró índice de fragilidad.RESULTADOS:Después de examinar 1271 citas, 15 ensayos aleatorios cumplieron los criterios de inclusión. Nueve de los estudios evaluaron intervenciones quirúrgicas y seis evaluaron intervenciones médicas. El número medio de pacientes aleatorizados y perdidos durante el seguimiento por ECA fue 92 (DE 35,3) y 9 (DE 11,4), respectivamente. La mediana del índice de fragilidad fue 1 (rango: 0-5). Los índices de fragilidad de los estudios incluidos no se correlacionaron significativamente con ninguna característica del estudio.LIMITACIONES:Muestra pequeña, heterogeneidad y falta de inclusión de estudios con resultados continuos.CONCLUSIONES:Los ensayos aleatorios que evalúan las intervenciones quirúrgicas y médicas para la enfermedad diverticular no son sólidos. Cambiar un solo evento de resultado en la mayoría de los estudios fue suficiente para que un hallazgo estadísticamente significativo del estudio no fuera significativo. (Traducción- Dr. Ingrid Melo ).

Nationwide volume-outcome relationship concerning in-hospital mortality and failure-to-rescue in surgery of sigmoid diverticulitis

PURPOSE

A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis.

METHODS

Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis.

RESULTS

In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly.

CONCLUSION

Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.

Anastomotic Considerations in Diverticulitis

Diverticulitis is a common indication for colorectal surgery, both in the acute and the elective setting. The anastomosis between the colon and rectum is a critical component of colectomy for diverticular disease and should be approached thoughtfully. This article reviews important surgical considerations when creating a colorectal anastomosis in the setting of diverticular disease, whether following the reversal of an end colostomy, during an acute episode of diverticulitis, or electively for chronic or complicated disease. Timing of surgery and preoperative assessment, minimally invasive approaches, and intraoperative maneuvers and considerations are discussed.

A systematic review and meta-analysis of robotic resections for diverticular disease

AIM

Resection of diverticular disease can be technically challenging. Tissue planes can be difficult to identify intraoperatively due to inflammation or fibrosis. Robotic surgery may improve identification of tissue planes and dissection which can facilitate difficult minimally invasive resections. This systematic review and meta-analysis evaluates the role of robotic surgery compared to laparoscopic surgery in diverticular resection.

METHODS

A systematic review and meta-analysis was performed in accordance with the PRISMA statement. The search was completed using PubMed, OVID MEDLINE and EMBASE. A total of 490 articles were retrieved, and studies reporting primary outcomes for robotic diverticular resection were included in the final analysis. A meta-analysis of studies comparing robotic and laparoscopic surgery was performed on rate of conversion to open surgery and complications.

RESULTS

Fifteen articles (8 cohort studies and 7 case series) reporting 3711 robotic diverticular resections were analysed. In comparison to laparoscopic, robotic surgery for diverticular disease was associated with a reduced conversion to open and a longer operating time. Meta-analysis showed robotic resection was associated with a lower conversion rate compared to laparoscopic surgery (OR: 0.57; 95% CI: 0.49-0.66, p < 0.001). There was no significant difference in grade III and above complications (OR: 0.74; 95% CI: 0.49-1.13, p = 0.17). Operating time was longer with a robotic approach (Hedge's G: 0.43; 95% CI: 0.04-0.81, p = 0.03).

CONCLUSION

Robotic resection is a feasible and safe option in diverticular disease. Although associated with a longer operating time, robotic surgery may render diverticular disease resectable with a minimally invasive approach that would have otherwise necessitated a laparotomy. Randomised controlled data is required to better define the role of robotic surgery for diverticular disease resections.

Burden of Colovesical Fistula and Changing Treatment Pathways: A Systematic Literature Review

PURPOSE

Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze contemporary literature data to appraise the current standard of care and changes of treatment algorithms over time.

MATERIALS AND METHODS

A systematic review of the literature on surgical management of CVF was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines.

RESULTS

Fourteen papers published between 2014 and 2020 and including 1061 patients were analyzed. One-stage colonic resection with primary anastomosis, with or without loop ileostomy, was the most common surgical procedure. A laparoscopic or robotic approach was attempted in 39.5% of patients, and conversion rate to open surgery was 7.8%. Clavien-Dindo grade ≥3 complication rate, 30-day mortality, and recurrence rate were 7.4%, 1.5%, and 0.5%, respectively.

CONCLUSIONS

Minimally invasive sigmoidectomy with primary anastomosis is safe and should be the first-choice approach for CVF. Bladder repair is not necessary after a negative intraoperative leak test. A standardized perioperative care can improve clinical outcomes and reduce the length of hospital stay and the duration of Foley catheterization.

Elective surgical versus conservative management of complicated diverticulitis: A systematic review and meta-analysis

OBJECTIVES

There is no consensus on the optimal treatment for patients with complicated diverticulitis. In this systematic review and meta-analysis we aimed to determine the indications for elective surgery in complicated diverticulitis by comparing conservative treatment with elective surgery.

METHODS

A meta-analysis of recurrence, morbidity and stoma rates was performed using a random effects model. Patient-reported quality of life (QoL) and cost-effectiveness outcomes were synthesized qualitatively.

RESULTS

Eleven randomized controlled trials and non-randomized studies with a total of 7415 patients were included. In statistical terms, the recurrence of diverticulitis was significantly higher in the conservatively treated group than in the elective surgery group (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.51). The stoma rate (OR 2.34, 95% CI 1.88-2.92) and the morbidity rate (OR 4.29, 95% CI 2.24-8.23) were significantly higher in the elective surgery group than in the conservatively treated group. There was some evidence for a significant increase in QoL and long-term cost-effectiveness in the elective surgery group than in the conservatively treated group.

CONCLUSIONS

Indications for elective surgery should not include the prevention of emergency colostomy or complications. Elective surgical resection may be considered in patients with complicated diverticulitis with the goal of improving their QoL and long-term cost-effectiveness.

Health-related quality of life and functional disorders after diverticular surgery

Diverticulosis and diverticulitis are leading indications for colorectal surgery in Western countries. Abdominal pain, functional disorders, and low health-related quality of life (HRQoL) can limit the outcome of abdominal surgery even in the absence of complications. Therefore, we aimed to review current evidence on postoperative long-term outcomes including HRQoL, functional disorders, abdominal pain, and patients' satisfaction after diverticular surgery for diverticulosis/diverticulitis. We performed a PubMed database search (inception: 17 December 2020). Identified publications were screened and outcome parameters extracted. In summary, HRQoL increased after diverticular surgery in 9 out of 10 longitudinal cohort studies. Similarly, patients' satisfaction with treatment and their choice to undergo surgery was commonly reported as high or very good, as reported in eight studies. In a randomized control trial and retrospective cohort, elective diverticular surgery was superior to conservative treatment regarding HRQoL. In cross-sectional analyses, chronic abdominal pain and functional disorders including defaecation disorders or diarrhoea/obstipation were found in a relevant fraction of patients. Incontinence ranged from 5% to 25% with insufficient data for comparison before and after surgery. However, functional disorders did not result in decreased HRQoL in most studies, and no increase in functional disorders was observed after elective diverticular surgery in longitudinal analyses. We conclude that HRQoL among operated patients with diverticular disease improved in most studies after surgery. Functional disorders and postoperative abdominal pain can be present after elective diverticular surgery; however, no increase in functional disorders was observed in longitudinal studies. Functional disorders after diverticular surgery need to be carefully discussed with the patient before surgery and a careful clinical assessment before surgery including incontinence scoring should be considered.

State-of-the-art surgery for sigmoid diverticulitis

Background

In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.

Purpose

This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.

Conclusion

Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Robotic-assisted surgery for complicated and uncomplicated diverticulitis: A single-surgeon case-series comparison

BACKGROUND

Robotic-assisted techniques in colorectal surgery have dramatically increased. Comparative data on the management of uncomplicated and complicated diverticulitis using robotics is lacking. The purpose of this study is to examine outcomes of patients who underwent robotic-assisted resection in diverticulitis.

METHODS

A prospectively maintained database performed by a single surgeon was retrospectively reviewed to identify patients who underwent robotic-assisted surgery (RAS) for diverticulitis from October 2009 to November 2018. Demographic data, preoperative and intraoperative parameters and postoperative outcomes were assessed using χ² or Fisher exact test with p values <0.05 considered significant. IRB approval was obtained for this study, #NCR190935.

RESULTS

Comparison revealed significant differences in operative times (222 vs. 291 min, p < 0.00001), mean estimated blood loss (130 vs. 304 cc, p = 0.0003) and mean length of stay (3.9 vs. 5.0 days, p = 0.006). Low rates of postoperative complications were observed, with no significant differences noted for conversion to laparoscopy, surgical site infection, leak, intra-abdominal abscess, 30-day unplanned readmission or recurrence.

CONCLUSION

Patients with complicated diverticulitis required longer operative time, had increased estimated blood loss and more often converted to an open procedure; however, overall rates of post-operative complications were low in both groups. RAS shows promise for use in complicated diverticulitis.

Minimally Invasive Management of Diverticular Disease

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis

BACKGROUND

Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting.

OBJECTIVE

The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis.

DESIGN

This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching.

SETTINGS

Interventions were performed in hospitals participating in the national database.

PATIENTS

Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat.

MAIN OUTCOME MEASURES

Outcomes measures included length of stay and overall morbidity and mortality.

RESULTS

Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates.

LIMITATIONS

Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors.

CONCLUSIONS

Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421.

ABORDAJE ABIERTO VERSUS MNIMAMENTE INVASIVO PARA COLECTOMA DE EMERGENCIA EN DIVERTICULITIS PERFORADA

ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomía con anastomosis primaria. La cirugía mínimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el mínimamente invasivo para la diverticulitis perforada emergente.DISEÑO:Ésta fue una revisión retrospectiva de la base de datos de colectomía dirigida del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propensión.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomía emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus mínimamente invasivo se definieron por intención de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duración de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusión (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos mínimamente invasivos. El grupo mínimamente invasivo se sometió a operaciones más prolongadas y tuvo tasas más bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duración de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje mínimamente invasivo se asoció con tiempos quirúrgicos más prolongados, pero también con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duración de la estancia. No se detectaron diferencias en las tasas de fuga anastomótica, mortalidad, reintervención o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, pérdida de datos, falta de uniformidad, sesgo de selección y errores de codificación.CONCLUSIONES:La anastomosis primaria mínimamente invasiva emergente resulta en una estancia más corta y una disminución de la morbilidad a los 30 días en comparación con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y mínimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizás debido a una tasa de conversión del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.

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

PURPOSE

Fifteen percent of patients undergoing elective sigmoidectomy will present a diverticulitis recurrence, which is associated with significant costs and morbidity. We aimed to systematically review the risk factors associated with recurrence after elective sigmoidectomy.

METHODS

PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies published until May 1, 2020. Original studies were included if (i) they included patients undergoing sigmoidectomy for diverticular disease, (ii) they reported postoperative recurrent diverticulitis, and (iii) they analyzed ≥ 1 variable associated with recurrence. The primary outcome was the risk factors for recurrence of diverticulitis after sigmoidectomy.

RESULTS

From the 1463 studies initially screened, six studies were included. From the 1062 patients included, 62 patients recurred (5.8%), and six variables were associated with recurrence. Two were preoperative: age (HR = 0.96, p = 0.02) and irritable bowel syndrome (33.3% with recurrence versus 12.1% without recurrence, p = 0.02). Two were operative factors: uncomplicated recurrent diverticulitis as indication for surgery (73.3% with recurrence versus 49.9% without recurrence, p = 0.049) and anastomotic level (colorectal: HR = 11.4, p = 0.02, or colosigmoid: OR = 4, p = 0.033). Two were postoperative variables: the absence of active diverticulitis on pathology (39.6% with recurrence versus 26.6% without recurrence) and persistence of postoperative pain (HR = 4.8, p < 0.01).

CONCLUSION

Identification of preoperative variables that predict the occurrence of diverticulitis recurrence should help surgical decision-making for elective sigmoidectomy, while peri- and postoperative factors should be taken into account for optimal patient follow-up.

The role of emergency laparoscopic surgery for complicated diverticular disease: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery develops rapidly in both elective and emergency settings. The study aimed to determine the role of different laparoscopic methods for the emergency treatment of complicated diverticulitis.

METHODS

MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to November 2019 to identify all published articles related to the topic. Statistical analysis was performed using Stata 15.

RESULTS

Fourteen publications were included in the analysis. Laparoscopic surgery was applied in 425 patients, and 493 patients underwent open colon resection (OCR). Postoperative mortality, morbidity, severe complications, and reoperation rates were not significantly different between the laparoscopic and open surgery groups. Subgroup analysis was performed based on the different laparoscopic methods (laparoscopic colon resection [LCR] and laparoscopic lavage and drainage [LLD]). Subgroup analysis indicated that LCR was superior to OCR in terms of morbidity, while OCR was superior to LLD in terms of severe complications.

CONCLUSIONS

The safety of laparoscopic surgery for the emergency treatment of complicated diverticulitis is related to different surgical methods. LCR is suggested to be a better choice according to the postoperative outcomes. More definite conclusions can be drawn in future randomized controlled trials.

Diverticulitis: An Update From the Age Old Paradigm

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Functional Results after Laparoscopic versus Robot-assisted Sigmoid Resection in Diverticulitis]

BACKGROUND

Sigmoid resection in diverticulitis is one of the most frequently performed colonic operations. A minimally invasive approach by laparoscopy is the surgical gold standard. For a few years now, sigmoid resections have also been performed robotically (da Vinci^® System). It is unclear whether there are relevant differences between the two procedures in terms of functional outcome.

METHODS

A postoperative follow-up was performed on all patients who underwent laparoscopic or robotic sigmoid resection for diverticulitis between November 2013 and November 2018, with a minimum interval of 6 months between surgery. Continence disorders, the development of symptoms compared to preoperative, changes in bowel movement (constipation, diarrhoea), impairment in daily life and pain were recorded. Differences between the groups were checked for statistical significance using the chi-square test.

RESULTS

During the study period, a total of 106 minimally invasive sigmoid resections for diverticulitis were performed (laparoscopic: n = 46, robot-assisted: n = 60). Of these, 74 patients (70%; laparoscopic: n = 28, robot-assisted: n = 46) answered the questionnaire and were included in the evaluation. Continence disorders were reported in a total of 22% of cases. There was no statistically significant difference between the groups in any of the variables surveyed.

CONCLUSION

With regard to functional results after minimally invasive sigmoid resection for diverticulitis, laparoscopic and robot-assisted sigmoid resection can be considered equivalent procedures.

No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease

BACKGROUND

Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long.

METHODS

A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010-2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups.

RESULTS

A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154-230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) CONCLUSIONS: Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.

Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis

BACKGROUND

Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.

METHODS

The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).

RESULTS

A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.

CONCLUSIONS

Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.

Randomized trial comparing low-pressure versus standard-pressure pneumoperitoneum in laparoscopic colectomy: PAROS trial

Background

Laparoscopy, by its minimally invasive nature, has revolutionized digestive and particularly colorectal surgery by decreasing post-operative pain, morbidity, and length of hospital stay. In this trial, we aim to assess whether low pressure in laparoscopic colonic surgery (7 mm Hg instead of 12 mm Hg) could further reduce pain, analgesic consumption, and morbidity, resulting in a shorter hospital stay.

Methods and analysis

The PAROS trial is a phase III, double-blind, randomized controlled trial. We aim to recruit 138 patients undergoing laparoscopic colectomy. Participants will be randomly assigned to either a low-pressure group (7 mm Hg) or a standard-pressure group (12 mm Hg). The primary outcome will be a comparison of length of hospital stay between the two groups. Secondary outcomes will compare post-operative pain, consumption of analgesics, morbidity within 30 days, technical and oncological quality of the surgical procedure, time to passage of flatus and stool, and ambulation. All adverse events will be recorded. Analysis will be performed on an intention-to-treat basis.

Trial registration

This research received the approval from the Committee for the Protection of Persons and was the subject of information to the ANSM. This search is saved in the ID-RCB database under registration number 2018-A03028–47. This research is retrospectively registered January 23, 2019, at http://clinicaltrials.gov/ed under the name “LaPAroscopic Low pRessure cOlorectal Surgery (PAROS)”. This trial is ongoing.

Totally laparoscopic and totally robotic surgery in patients with left-sided colonic diverticulitis

BACKGROUND

Introduction of the da Vinci Xi system has facilitated the use of robotics in colorectal surgery. Nevertheless, data on the outcomes of robotic surgery for the treatment of colonic diverticulitis have remained scarce.

METHODS

Patient demographics, clinical characteristics, and perioperative outcomes of the patients undergoing totally robotic with the da Vinci Xi system or laparoscopic surgery for left-sided colonic diverticulitis (LCD) were compared.

RESULTS

Laparoscopic and robotic groups included 22 and 20 patients, respectively. There were no significant differences between the two groups in terms of patient demographics, clinical characteristics, operative time, and postoperative complications. There were three conversions in the laparoscopy group and no conversion in the robotic group (P = 0.23). Conversion to open surgery was associated with postoperative morbidity (P = 0.02).

CONCLUSION

Robotic surgery is an applicable alternative for the treatment of LCD. Robotic approach may potentially lower the risk of operative morbidity by reducing the requirement of conversion.

Laparoscopic surgery for colovesical fistula associated with sigmoid colon diverticulitis: a review of 39 cases

Objectives: Colonic diverticular disease is widespread in Western countries and its associated with aging. In Japan, diverticulitis and colovesical fistula are also occurring more frequently. Colonic resection for diverticula-related fistulas is frequently technically demanding because of associated acute or chronic inflammation. We evaluated the safety and efficacy of a standardized laparoscopic procedure. Methods: Data from 39 consecutive patients who had undergone laparoscopic surgery for colovesical fistula between October 2006 and August 2017 were retrospectively reviewed. Results: The patients' median age was 60 years and comprised 35 men and four women. Sigmoidectomy was performed in 33 patients, Hartmann's procedure in four, and anterior resection in two. The median operative time was 203 minutes and estimated blood loss 15 mL. There were no intraoperative complications or conversion to open surgery. No patients required bladder repair; three had minor postoperative complications, and none had recurrent diverticulitis or fistula at a mean follow-up of 5.1 years. Conclusions: The magnified vision and minimal invasiveness make a laparoscopic approach the ideal means of managing colovesical fistula. To our knowledge, this is the largest study of colovesical fistula managed by a standardized laparoscopic procedure.

Robotic pelvic dissection as surgical treatment of complicated diverticulitis in elective settings: a comparative study with fully laparoscopic procedure

BACKGROUND

Recently, minimally invasive treatment of complicated sigmoid diverticulitis is becoming a valid alternative to standard procedures. Robotic approach may be useful to allow more precise dissection in arduous pelvic dissection as in complicated diverticulitis. The aim of this study is to investigate effectiveness, potential benefits and short-term outcomes of robotic-assisted laparoscopic surgical resection, compared with fully laparoscopic resection in complicated diverticulitis.

METHODS

Between January 2009 and December 2017, 156 consecutive patients with history of complicated diverticular disease were referred to our Department of General, Mininvasive and Robotic Surgery. All patients underwent elective colonic resections performed by the same colorectal surgeon and followed a perioperative ERAS program. Demographic and clinical features, surgical data, postoperative data, 30-day morbidity and mortality, VAS for surgeon's compliance were evaluated.

RESULTS

One hundred and fifty-six consecutive patients underwent elective colonic resection: 92 fully laparoscopic (FL) colorectal resections and 64 procedures with robotic hybrid approach (RHA). Conversion rate was none in the RHA group versus 6.5% in the FL group, because of poor vision due to bowel distension, inflammatory pseudotumor and peritoneal adhesions. No 30-day mortality was observed. Mean operative time was 167.5 ± 54.4 min (80-420) in the FL group and 172.5 ± 55.64 min (110-325) in the RHA group (p 0.079), mean intraoperative blood loss was 144.6 ± 40.6 ml (40-200) with the FL technique and 138.4 ± 28.3 ml (20-185) with the RHA (p 0.295). Mean hospital stay for FL was 5 ± 4.1 days (range 3-45) and 5 ± 2.7 days (range 3-20) for RHA (p 0.974). Overall postoperative morbidity rate was 21.6% in the FL group and 12.3% in the RHA (p 0.067). Major postoperative morbidity (Clavien-Dindo 3 and 4) represented 13% and 4.6%, respectively (p 0.091). VAS for surgeon's compliance revealed a better performance in the robotic arm (p 0.059).

CONCLUSIONS

This preliminary study highlights the potential benefits of robotic-assisted laparoscopy in colorectal resections for complicated diverticular disease in terms of surgical efficacy, postoperative morbidity and better surgeon's compliance.

Suprapubic single-port approach for complicated diverticulitis

BACKGROUND

Laparoscopic sigmoidectomy is the gold standard for elective surgical treatment of diverticulitis. A periumbilical single-port technique reduces the size of the access wound, usually to 3-4 cm. However, in the presence of large phlegmon or fistulae, the risk of conversion is higher and the extraction site might be enlarged. A suprapubic Pfannenstiel incision reduces the risk of incisional hernia compared to umbilical access and might provide the possibility to perform sigmoidectomy with a hybrid technique. The aim of the present study was to investigate the feasibility of laparoscopic sigmoidectomy through a single suprapubic transverse access for large diverticular phlegmon.

METHODS

Consecutive patients with a diverticular inflammatory mass ≥ 5 cm, with or without sigmoid-vesical fistula, were considered candidates for laparoscopic sigmoidectomy through a 5-cm single-port suprapubic (SPSP) access, extended (if required) to match the size of the inflammatory mass.

RESULTS

Twenty patients underwent SPSP sigmoidectomy at our institution in April 2014-April 2017. All procedures were completed by SPSP access, with no intraoperative complications or need for additional trocar placement. Eight patients had a sigmoid-vesical fistula (bladder sutured in three patients). The splenic flexure was mobilized in nine patients. Median operative time was 178 min and median hospital stay was 5.5 days (iqr 4-6). Postoperative complications occurred in four patients and included one subcutaneous hematoma, one urinary tract infection, and two superficial wound infections. After a median follow-up time of 25 months (interquartile range 15-38), all patients experienced complete resolution of symptoms, with no incisional hernias reported.

CONCLUSIONS

SPSP sigmoidectomy for diverticulitis is feasible and effective, minimizing the size of the access wound and avoiding increased risk of hernia. This approach might be especially valuable for the management of large diverticular phlegmon and sigmoid-vesical fistula.

Progress and challenges in the management of diverticular disease: which treatment?

Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.

Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials

PURPOSE

The surgical interventions of diverticulitis vary according to its grade and severity. There is a controversy about the best of these different surgical procedures. We aimed to systematically review and meta-analyze randomized controlled trials (RCTs) comparing outcomes and complications between different surgical approaches for acute diverticulitis and its complications.

METHODS

Nine electronic databases including PubMed, Scopus, and Web of Science were searched for RCTs comparing different surgical procedures for different grades of diverticulitis. The risk of bias was assessed using the Cochrane Collaboration tool. The protocol was registered in PROSPERO (CRD42015032290).

RESULTS

Outcome data were analyzed from five RCTs comparing laparoscopic sigmoid resection (LSR) (n = 247) versus open sigmoid resection (OSR) (n = 237) for treatment of acute complicated diverticulitis with minimal heterogeneity. There was no significant difference in short-term postoperative overall morbidity (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.61-1.31; P = 0.56) and long-term postoperative major morbidity (RR 0.78, 95% CI 0.46-1.31, P = 0.34). In other six RCTs compared laparoscopic lavage with resection for treatment of perforated diverticulitis with peritonitis, the postoperative mortality rate was non-significant in both short-term (RR 1.55, 95% CI 0.79-3.04; P = 0.21) and long-term (RR 0.67, 95% CI 0.29-1.58; P = 0.36) follow up.

CONCLUSIONS

LSR is not superior over OSR regarding postoperative morbidity and mortality for acute symptomatic diverticulitis. Furthermore, laparoscopic lavage was proved to be as safe as resection for perforated diverticulitis with peritonitis. Further RCTs are still needed to make an accurate decision regarding these and other procedures.

Laparoscopic versus open resection for sigmoid diverticulitis

BACKGROUND

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

OBJECTIVES

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

MAIN RESULTS

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann's procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

AUTHORS' CONCLUSIONS

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).

Colovesical Fistula Complicating Diverticular Disease: A 14-Year Experience

OBJECTIVE

Colovesical fistulas (CVF) constitute the most common type of spontaneously occurring fistulas associated with diverticular disease. One-stage laparoscopic resection has been shown to be feasible, but studies comparing this approach to open surgery are scarce. The aim of this study was to compare the clinical outcomes of open and laparoscopic surgery for CVF of diverticular origin.

MATERIALS AND METHODS

From January 2000 to July 2014, 37 colectomies were performed for diverticular disease-related CVF. Twenty-eight patients who underwent resection and primary anastomosis were divided in 2 groups: the laparoscopic surgery group (group A) and the open surgery group (group B). We have analyzed the following parameters: operative time, complication rate, hospital stay, recurrence, and early mortality rate.

RESULTS

Groups A and B were comparable in terms of age, sex, diverticulitis episodes, previous abdominal surgery, and body mass index.The mean duration of surgery was significantly shorter in group B: 175 versus 237 minutes (P=0.011). There was a faster recovery of gastrointestinal transit in group A (2 vs. 13; P=0, 0002). However, there were no significant differences between the groups with respect to serious postoperative morbidity [(Clavien-Dindo scores of 3, 4, and 5) 4 vs. 0; P=0.098)] and with respect to hospital stay (10.5 vs. 9.5 d; P=0.537). There was no recurrence during a median follow-up of 12 months.

CONCLUSIONS

Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of diverticular CVF. Despite progresses in minimally invasive colorectal surgery, the conversion rate and morbidity are still high.

Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.

Laparoscopic Approach in Colonic Diverticulitis: Dispelling Myths and Misperceptions

BACKGROUND/AIM

Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant morbidity and mortality. In this review of the literature, we aim to assess the feasibility and effectiveness of the laparoscopic approach in both elective and emergency setting of diverticular disease.

MATERIALS AND METHODS

A bibliographic search of articles was performed using the electronic database Medline from PubMed. Of 341 articles identified, 279 were excluded, resulting in 62 full-text articles for review. Our final review included 16 articles.

RESULTS

The 16 articles included in the final review consisted of 6 retrospective studies, 5 prospective studies, 2 randomized controlled trials, 1 systematic review and meta-analysis, and 2 systematic reviews. Seven articles considered elective laparoscopic sigmoid resection, 7 articles evaluated laparoscopic peritoneal lavage, and 2 articles considered emergency laparoscopic sigmoid resection for perforated diverticulitis. The elective laparoscopic approach is feasible and safe. Laparoscopic peritoneal lavage has emerged as a safe and effective minimally invasive procedure for the treatment of perforated diverticulitis. Furthermore, in selected patients, emergency laparoscopic sigmoidectomy could also be feasible for perforated diverticulitis with generalized peritonitis.

CONCLUSIONS

Laparoscopic approach can be a safe and effective option in both elective and emergency setting of diverticular disease. Large, prospective, randomized studies should be conducted to confirm these findings.

Laparoscopy for Benign Diseases of the Colon

Laparoscopic surgery has revolutionized the delivery of care to the surgical patient undergoing colorectal resection. Since the first laparoscopic-assisted colectomy in 1991, significant advances have been made in minimally invasive colorectal surgery. For many benign conditions, laparoscopic colectomy has been proven to be safe and effective, and in some instances superior when compared with open surgery. Complex laparoscopic resections such as those for diverticulitis and inflammatory bowel disease have also been shown to have equivalent outcomes when compared with open surgery. Short-term benefits of a minimally invasive approach include less pain, decreased rates of wound infection and postoperative morbidity, faster return of bowel function, and shorter length of stay. Improvements in long-term complications have also been noted with lower incidence of incisional hernias and small bowel obstructions secondary to adhesions. As surgeons become more facile with laparoscopic resection, more complex cases such as those for complicated diverticulitis and reoperative surgery for inflammatory bowel disease can be completed with shorter operative times and decreased cost.

National complicated acute diverticulitis (CADS) study: a protocol for a prospective observational scoping study for acute diverticulitis

Background

Diverticular disease is a widely prevalent disease in western society, and acute diverticulitis is a common acute surgical presentation. However, there is a lack of level 1 evidence addressing the multifaceted presentations associated with acute diverticulitis. There is also a lack of robust epidemiological data that could be used to meaningfully inform randomised controlled trials. The National CADS project aims to generate baseline data for a cohort of patients managed for clinically suspected acute diverticulitis and evaluate the impact of variability in the management approach on patient outcomes in the short (3 months) and long (2 years) term.

Method

A Unit policy questionnaire will be completed by the principal investigator from all participating centres prior to study initiation. All patients aged above 18 years admitted with clinical suspicion of acute diverticulitis will be included from UK hospitals providing acute surgical care. Demographic, clinical, inpatient stay and outpatient follow-up data will be collected for index admissions between July and September 2014, 3 months follow-up and finally a 2-year follow-up.

Results

The study attracted participation from 108 centres nationally and has so far generated data on 2500 patients admitted between 1 July 2014 and 30 September 2014. Short-term follow-up data have been obtained for this cohort.

Conclusions

The National CADS study is currently ongoing with the long-term outcomes data anticipated to be submitted in autumn of 2016.

Impact of frailty on approach to colonic resection: Laparoscopy vs open surgery

AIM

To understand the influence of frailty on postoperative outcomes for laparoscopic and open colectomy.

METHODS

Data were obtained from the National Surgical Quality Improvement Program (2005-2012) for patients undergoing colon resection [open colectomy (OC) and laparoscopic colectomy (LC)]. Patients were classified as non-frail (0 points), low frailty (1 point), moderate frailty (2 points), and severe frailty (≥ 3) using the Modified Frailty Index. 30-d mortality and complications were used as the primary end point and analyzed for the overall population. Complications were grouped into major and minor. Subset analysis was performed for patients undergoing colectomy (total colectomy, partial colectomy and sigmoid colectomy) and separately for patients undergoing rectal surgery (abdominoperineal resection, low anterior resection, and proctocolectomy). We analyzed the data using SAS Platform JMP Pro version 10.0.0 (SAS Institute Inc., Cary, NC, United States).

RESULTS

A total of 94811 patients were identified; the majority underwent OC (58.7%), were white (76.9%), and non-frail (44.8%). The median age was 61.3 years. Prolonged length of stay (LOS) occurred in 4.7%, and 30-d mortality was 2.28%. Patients undergoing OC were older (61.89 ± 15.31 vs 60.55 ± 14.93) and had a higher ASA score (48.3% ASA3 vs 57.7% ASA2 in the LC group) (P < 0.0001). Most patients were non-frail (42.5% OC vs 48% LC, P < 0.0001). Complications, prolonged LOS, and mortality were significantly more common in patients undergoing OC (P < 0.0001). OC had a higher risk of death and complications compared to LC for all frailty scores (non-frail: OR = 4.7, and OR = 4.67; mildly frail: OR = 2.51, and OR = 2.47; moderately frail: OR = 2.94, and OR = 2.02, severely frail: OR = 2.37, and OR = 2.34, P < 0.05) and an increase in absolute mortality with increasing frailty (non-frail 0.68% OC, mildly frail 1.39%, moderately frail 3.44%, and severely frail 5.83%, P < 0.0001).

CONCLUSION

LC is associated with improved outcomes. Although the odds of mortality are higher in non-frail, there is a progressive increase in mortality with increasing frailty.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Laparoscopic approach in complicated diverticular disease

AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.

METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease (abscess, perforation, fistula, or stenosis) (G1) and patients undergoing surgery for recurrent diverticulitis (G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.

RESULTS: Two hundred and sixty patients were included: 28% (72 patients) belonged to G1 and 72% (188 patients) to G2. The mean age was 57 (27-89) years. The average number of episodes of diverticulitis before surgery was 2.1 (r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay (G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups (G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data (body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38% (1 patient), represented by a death secondary to septic shock in G2.

CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.

Effectiveness of elective laparoscopic treatment for colonic diverticulitis

Background and Objectives:

To analyze the short- and long-term outcomes of laparoscopic sigmoid colectomy for the elective treatment of diverticular disease.

Methods:

A consecutive unselected series of 94 patients undergoing elective laparoscopic sigmoid colectomy for diverticular disease from 2008 to 2012 was analyzed. We collected patients-, surgery- and hospital stay–related data, as well as the short- and long-term outcomes. Operative steps, instrumentation, and postoperative cares were standardized. Comorbidity was assessed by Charlson comorbidity index. Complications were classified using the Clavien-Dindo classification system. The qualitative long-term assessment was carried out by subjecting patients to the validated gastrointestinal quality of life index questionnaire before and after surgery.

Results:

The mean age of our cohort was 61.3 ± 11.0 years with a Charlson comorbidity index of 1.2 ± 1.5.

Mean operative time was 213.5 ± 60.8 minutes and estimated blood loss was 67.2 ± 94.3 mL. We had 3 cases (3.2%) of conversion to open laparotomy. The rates of postoperative complications were 35.1%, 6.3%, 2.1%, and 1.06%, respectively, for grades 1, 2, 3b, and 5 according to the Clavien-Dindo system. Length of hospital stay was 8.1 ± 1.9 days, and we have not recorded readmissions in patients discharged within 60 days after surgery. Median follow-up was of 9.6 ± 2.7 months. We observed no recurrence of diverticular disease, but there was evidence of 3 cases of incisional hernia (3.19%). The difference between preoperative and late gastrointestinal quality of life index score was statistically significant (97.1 ± 5.8 vs 129.6 ± 8.0).

Conclusions:

Elective laparoscopic treatment of colonic diverticular disease represents an effective option that produces adequate postoperative results and ensures a satisfactory functional outcome.

Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.

METHODS

We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854).

RESULTS

We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment.

CONCLUSIONS

On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

[Treatment of the acute diverticulitis: A systematic review]

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.