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Connelly TM, Cheong JY, Lincango EP, Foley N, Clancy C, Valente M, Kessler H. Low incidence of occult colorectal carcinoma in a cohort of 150 consecutive patients with diverticular strictures. Surgery 2023; 174:487-491. [PMID: 37296056 DOI: 10.1016/j.surg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/23/2023] [Accepted: 04/09/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The symptoms of stricturing diverticulitis can overlap with those of colorectal cancer. Additionally, the stricture itself may mask a "hidden" colorectal cancer. We aimed to describe the demographics, operative details and outcomes, including occult colorectal cancer, in a cohort of consecutive resections for presumed diverticular strictures. METHODS In this single-center, retrospective cohort study, all patients undergoing resection for a presumed diverticular stricture between January 2010 and December 2015 were included. Preoperative imaging and colonoscopies were individually reviewed. Only patients with radiographically, endoscopically and/or intraoperatively benign-appearing strictures were included. RESULTS One hundred fifty patients (72.7% female, mean age = 70.4 ± 11.8 years, 62.7% elective) were included. Only 34 (22.7%) had a complete preoperative colonoscopy. In 95 (63.6% of cohort) patients, the stricture was non-traversable colonoscopically. Overall, 47 (31.3%) patients did not have complete preoperative imaging or a colonoscopy. In total, 53.3% were open procedures and 62% had non-diverted primary anastomosis. Eleven (14.7%) underwent resection of adjacent organs (5 appendixes/5 right colons/7 fallopian tubes ± ovaries/3 small bowel resections/2 partial cystectomies/1 spleen). The median length of stay was 7 (5, 12.5) days. Only 2 cancers (1.3% of patients) involving the stricture (1 invasive moderately differentiated sigmoid adenocarcinoma/1 lymphoma) were found. Three additional cancers were found in organs involved in the inflammatory process (20% of concomitantly resected organs, 1 ovarian carcinoma/1 leukemia in a lymph node/1 appendiceal tumor). CONCLUSION Despite approximately one-third of the cohort not having undergone successful preoperative colonoscopy or imaging, the rate of neoplasia involving diverticular strictures was only 1.3%. A relatively high cancer rate was found in concomitantly resected organs involved in the stricturing process.
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Affiliation(s)
- Tara M Connelly
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/TaraMConnelly
| | - Ju Yong Cheong
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/JUYONGCHEONG1
| | - Eddy P Lincango
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/DoctorEddyMD
| | - Niamh Foley
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/nnifhoghlu
| | - Cillian Clancy
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH
| | - Michael Valente
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH. https://twitter.com/DrMikeValente
| | - Hermann Kessler
- Digestive Disease and Surgery Institute, Department of Colorectal Surgery, Cleveland Clinic, OH.
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Cirocchi R, Popivanov G, Corsi A, Amato A, Nascimbeni R, Cuomo R, Annibale B, Konaktchieva M, Binda GA. The Trends of Complicated Acute Colonic Diverticulitis-A Systematic Review of the National Administrative Databases. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:medicina55110744. [PMID: 31744067 PMCID: PMC6915450 DOI: 10.3390/medicina55110744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 02/05/2023]
Abstract
Background and Objectives: The diverticular disease includes a broad spectrum of different "clinical situations" from diverticulosis to acute diverticulitis (AD), with a full spectrum of severity ranging from self-limiting infection to abscess or fistula formation to free perforation. The present work aimed to assess the burden of complicated diverticulitis through a comparative analysis of the hospitalizations based on the national administrative databases. Materials and Methods: A review of the international and national administrative databases concerning admissions for complicated AD was performed. Results: Ten studies met the inclusion criteria and were included in the analysis. No definition of acute complicated diverticulitis was reported in any study. Complicated AD accounted for approximately 42% and 79% of the hospitalizations. The reported rates of abscess varied between 1% and 10% from all admissions for AD and 5-29% of the cases with complicated AD. An increasing temporal trend was found in one study-from 6% to 10%. The rates of diffuse peritonitis ranged from 1.6% to 10.2% of all hospitalizations and 11% and 47% of the complicated cases and were stable in the time. Conclusions: The available data precluded definitive conclusions because of the significant discrepancy between the included studies. The leading cause was the presence of heterogeneity due to coding inaccuracies in all databases, absence of ICD codes to distinguish the different type of complications, and the lack of coding data about some general conditions such as sepsis, shock, malnutrition, steroid therapy, diabetes, pulmonary, and heart failure.
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Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery and Surgical Oncology, Hospital of Terni, University of Perugia, 05100 Terni, Italy;
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
- Correspondence:
| | - Alessia Corsi
- Chirurgia Generale, Ospedale della Media Valle del Tevere, via del Buda, 06059 Todi, Italy;
| | - Antonio Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, 18038 Sanremo, Italy;
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy;
| | - Rosario Cuomo
- Gastroenterology and Digestive Endoscopy Unit, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Bruno Annibale
- Department of Medical Surgery, Sciences and Translational Medicine University Sapienza, 00189 Rome, Italy;
| | - Marina Konaktchieva
- Department of Gastroenterology and Hepatology, Military Medical Academy, ul. “Sv. Georgi Sofiiski“ 3, 1606 Sofia, Bulgaria;
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Abstract
PURPOSE OF REVIEW While few diseases are limited solely to the elderly, diverticular disease is clearly more prevalent with increasing age and therefore the aim of this review is to focus on the clinical implications of diverticular disease in the elderly. RECENT FINDINGS Diverticulitis in the elderly is best managed with an individualized treatment approach including considerations for selective antibiotic usage even in uncomplicated disease. Furthermore, due to the increased prevalence of ischemic colitis in the elderly and the similarities in presentation with diverticular hemorrhage, there needs to be a high index of suspicion and appropriate evaluation for ischemic colitis in patients with hematochezia, particularly if they have abdominal pain. The elderly are a vulnerable population where the index of suspicion for complications of diverticular disease should be high.
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Affiliation(s)
- Mona Rezapour
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Neil Stollman
- Alta Bates Summit Medical Center, East Bay Center for Digestive Health, 300 Frank H Ogawa Plaza, Suite 450, Oakland, CA, 94612, USA.
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4
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Factors associated with diverticular bleeding and re-bleeding: A United States hospital study. North Clin Istanb 2018; 6:248-253. [PMID: 31650111 PMCID: PMC6790935 DOI: 10.14744/nci.2018.23540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/06/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE: Diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Arteriovascular disease, metabolic syndromes, non-steroidal anti-inflammatory drugs (NSAIDs), anti-thrombotics, and anticoagulants have been suggested as risk factors. There is a paucity of studies addressing factors associated with diverticular re-bleeding, especially in the United States. The aim of this study is to evaluate factors associated with colonic diverticular bleeding and re-bleeding in a US community-based hospital. METHODS: We conducted a retrospective case-control study to analyze the factors associated with diverticular bleeding. Between January 2010 and July 2011, 93 patients were admitted to our hospital with a primary diagnosis of acute diverticular bleeding. We compared them to 152 patients who were admitted with a primary diagnosis of diverticulitis in the same period. We collected data from the medical records of each patient in relation to the demographics, comorbidities, medications, social habits, location of diverticulosis, length of stay in the hospital, and re-bleeding rate within 2 years of the first bleeding episode. RESULTS: Factors such as cerebrovascular accident (p=0.009), coronary artery disease (p=0.037), diabetes mellitus (p=0.046), obstructive sleep apnea (p=0.033), NSAIDs (p=0.038), use of anti-thrombotics (p=0.001), anticoagulants (p=0.002) or calcium channel blockers (p=0.009), and bilateral diverticulosis (p=0.001) were significantly associated with diverticular bleeding as compared to diverticulitis. Recurrence of bleeding was noted in 26 out of 93 patients (28%) within 2 years of the first bleeding episode (p=0.001). Bilateral colonic involvement, anticoagulants, and elderly age (≥65 years) were found to have a closer relationship to diverticular re-bleeding, although it was not statistically significant. CONCLUSION: This study reveals that arteriovascular disease, diabetes mellitus, NSAIDs, the use of anti-thrombotics, anticoagulants or calcium channel blockers, and obstructive sleep apnea are factors that are significantly associated with diverticular bleeding. It also shows that bilateral colonic involvement, elderly age, and anticoagulants have a closer relationship to diverticular re-bleeding. More prospective studies in patients with diverticular bleeding should be conducted to shed light on the causality of these factors and the prevalence of diverticulitis.
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5
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Teixeira C, Trabulo D, Ribeiro S, Martins CR, Alves AL, Cremers I, Oliveira AP. Colonic diverticulosis and the metabolic syndrome: an association? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:768-771. [PMID: 28776378 DOI: 10.17235/reed.2017.5009/2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. METHODS This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. RESULTS The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Age-adjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. CONCLUSION In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD.
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Affiliation(s)
| | - Daniel Trabulo
- Gastroenterology, Centro Hospitalar de Setúbal, Portugal
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6
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Farkas N, Kaur V, Shanmuganandan A, Black J, Redon C, Frampton AE, West N. A systematic review of gallstone sigmoid ileus management. Ann Med Surg (Lond) 2018; 27:32-39. [PMID: 29511540 PMCID: PMC5832643 DOI: 10.1016/j.amsu.2018.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/07/2018] [Accepted: 01/21/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Gallstone sigmoid ileus is a rare although serious complication of cholelithiasis resulting in large bowel obstruction. The condition accounts for 4% of all gallstone ileus patients. There are no recognized management guidelines currently. Management strategies range from minimally invasive endoscopy and lithotripsy to substantial surgery. We aim to identify trends when managing patients with gallstone sigmoid ileus to help improve outcomes. METHODS Literature searches of EMBASE, Medline and by hand were conducted. All English language papers published from 2000 to 2017(Oct) were included. The terms 'gallstone', 'sigmoid', 'colon', 'ileus', 'coleus' and 'large bowel obstruction' were used. RESULTS 38 papers included, male:female ratio was 8:30. Average age was 81.11 (SD ± 7.59). Average length of preceding symptoms was 5.31days (+/-SD3.16). 20/38 (59%) had diverticulosis. 89% of patients had significant comorbidities documented. 34/38 patients underwent computerized tomography. 31 stones were located within sigmoid colon, 4 at rectosigmoid junction and 2 within descending colon. Average impacted gallstone size was 4.14 cm (2.3-7 cm range). 23/38 (61%) patients' initial management was conservative or with endoscopy ± lithotripsy. Conservative management successfully treated 26% of patients. 28/38 (74%) patients ultimately underwent surgical intervention. 5/38 patients died post-operatively. Patients treated non-operatively had shorter hospital stays (4:12.3days) although not significant (p-value = 0.0056). CONCLUSIONS There is no management consensus from the literature. Current evidence highlights endoscopy and lithotripsy as practical firstline strategies. However, surgical intervention should not be delayed if non-operative measures fail or in emergency. Given the complexity of such patients, less invasive timesaving surgery appears practical, avoiding bowel resection and associated complications.
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Affiliation(s)
- Nicholas Farkas
- Epsom and St Helier University Hospitals, Wrythe Lane, Carshalton, Sutton, London, SM5 1AA, United Kingdom
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7
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Yang F, Zheng Y, Jiang X, Su Z, Wang Y, Lin L, Lv H, Zhang J, Zhao J, Wang B, Jiang K, Sun C. Sex differences in risk factors of uncomplicated colonic diverticulosis in a metropolitan area from Northern China. Sci Rep 2018; 8:138. [PMID: 29317721 PMCID: PMC5760586 DOI: 10.1038/s41598-017-18517-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/12/2017] [Indexed: 02/06/2023] Open
Abstract
As the world’s most populated and rapidly aging country, there is limited information on sex-related differences in factors regarding uncomplicated colonic diverticulosis in China. We aimed to investigate sex differences in individual risk factor in a northern metropolis. Patients with colonic diverticulosis who underwent indicated colonoscopy were queried with respect to medical history and demographic features. Demographic information, life style factors and co-morbidities were retrieved from a prospective dataset. Multiple regression analyses were performed to determine precipitating factors of diverticula. Of 4,386 enrolled patients, colonic diverticulosis were detected in 218 cases (4.97%). Multiple logistic regression analysis implicated increasing age (OR = 1.05, 95%CI 1.03–1.06, P < 0.001), red meat ≥100 g/d (OR = 2.53, 95%CI 1.72–3.70, P < 0.001), smoking (OR = 2.14, 95%CI 1.05–4.33, P = 0.035), rheumatologic diseases (OR = 3.38, 95%CI 1.09–10.5, P = 0.035) and NSAIDs (OR = 2.11, 95%CI 1.12–3.97, P = 0.020) were significantly associated with diverticulosis in men, whilst advancing age (OR = 1.03, 95%CI 1.01–1.05, P = 0.013), BMI (OR = 1.12, 95%CI 1.04–1.19, P = 0.001), smoking (OR = 10.2, 95%CI 2.81–37.4, P < 0.001), rheumatologic diseases (OR = 8.04, 95%CI 3.05–21.2, P < 0.001), hypertension (OR = 1.76, 95%CI 1.01–3.06, P = 0.047), colonic polyps (OR = 3.12, 95%CI 1.82–5.36, P < 0.001) and antihypertensive medications (OR = 2.99, 95%CI 1.66–5.39, P < 0.001) in women. In conclusion, it is pivotal to take account of differentially sex-related factors in regard to the development of uncomplicated colonic diverticulosis.
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Affiliation(s)
- Fang Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Yanmin Zheng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Xihui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Zhengyan Su
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Ya Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Lin Lin
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Houning Lv
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Jingwen Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China
| | - Kui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China. .,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China. .,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300052, China.
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8
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Focchi S, Carrara A, Avesani EC. Advances in management of patients with acute diverticulitis. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Vather R, Broad JB, Jaung R, Robertson J, Bissett IP. Demographics and trends in the acute presentation of diverticular disease: a national study. ANZ J Surg 2015; 85:744-8. [PMID: 25925134 DOI: 10.1111/ans.13147] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diverticular disease (DD) is a major health problem in the Western world. The aim of this study was to describe demographics and trends in acute DD admissions in New Zealand. METHODS Information pertaining to acute hospital admissions between January 2000 and June 2012 for a primary diagnosis of large bowel DD was retrieved from a national database. RESULTS There were 25,167 admissions for acute DD. Mean age of presentation decreased from 65.9 years in 2000 to 64.1 years in 2012 (P < 0.001). Mean age was lower in men than women (61.4 versus 67.4 years, P < 0.001). Although men comprised 45.2% of the cohort they were over-represented in the 18-44 years stratum (68.6 versus 31.4%; P < 0.001). Europeans accounted for 84.8% of admissions and presented at an older age (65.8 years) than Māori (56.2 years), Pacific Islanders (58.4 years) or Asians (58.9 years) (P < 0.001). Acute DD admissions were higher in more deprived populations (P < 0.001). Mean length of hospital stay (LOS) reduced from 5.8 days in 2000 to 4.1 days in 2012 (P < 0.001). LOS increased with age (P < 0.001) and deprivation (P = 0.013), but did not differ between ethnicities (P = 0.088). Computed tomography scanning of acute admissions doubled from 2000 to 2012 (29.7-59.2%; P < 0.001) with a halving in the use of acute in-patient colonoscopy (26.1-13.2%; P < 0.001) and emergent surgery (14.8-7.2%; P < 0.001). Percutaneous drain use increased from 0.6% in 2000 to 1.1% in 2012 (P = 0.003). CONCLUSION Acute DD is a source of considerable morbidity in New Zealand and there have been significant changes in its admission demographics and trends over the last decade.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Joanna B Broad
- Freemasons' Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Rebekah Jaung
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Jason Robertson
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Pilgrim SM, Hart AR, Speakman CTM. Diverticular disease in younger patients--is it clinically more complicated and related to obesity? Colorectal Dis 2014; 15:1205-10. [PMID: 23531175 DOI: 10.1111/codi.12225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 11/21/2012] [Indexed: 12/19/2022]
Abstract
AIM The aims of this systematic review were to determine the presentations of diverticular disease in patients under 40 years of age and to assess whether obesity is an important factor. METHOD The PubMed and EMBASE databases and the Cochrane Library were searched to identify all original articles published between 1990 and 2011 on diverticular disease severity in obese patients (body mass index of ≥ 30 kg/m(2) ) under 40 years of age. RESULTS Twenty-three clinical case series (two of which were prospective) were identified plus two large aetiological population-based studies. These reported that young patients with diverticular disease were presenting more frequently, that diverticular disease in this age group was less likely to be complicated but that emergency operation rates were higher. The majority (63.1-96.5%) of patients under 40 years of age with diverticular disease were obese. CONCLUSION The studies suggest that in the young, obese patient with lower abdominal pain, diverticulitis and appendicitis are included in the differential diagnosis. CT and/or laparoscopy should be considered where the diagnosis is in doubt.
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Affiliation(s)
- S M Pilgrim
- Department of General Surgery, Norfolk & Norwich University Hospital, Norwich, UK
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Abstract
BACKGROUND AND OBJECTIVES A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula. METHODS A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period. RESULTS Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence. CONCLUSIONS Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.
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Affiliation(s)
| | - Anna T Tsay
- Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA
| | - Maher A Abbas
- Chair, Minimally Invasive and Robotic Surgery, 4760 Sunset Boulevard, Third Floor, Los Angeles, CA 90027, USA.
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Risk of Readmission and Emergency Surgery Following Nonoperative Management of Colonic Diverticulitis. Ann Surg 2014; 260:423-30; discussion 430-1. [DOI: 10.1097/sla.0000000000000870] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Jovani M, Genco C, Bravatà I, Repici A. Stents in the management of benign colorectal strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Younger age and prognosis in diverticulitis: a nationwide retrospective cohort study. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:95-8. [PMID: 23472245 DOI: 10.1155/2013/341501] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traditionally regarded as a disease of the elderly, the incidence of diverticulitis of the colon has been on the rise, especially in younger cohorts. These patients have been found to experience a more aggressive disease course with more frequent hospitalization and greater need for surgical intervention. OBJECTIVE To characterize factors that portend a poor prognosis in patients diagnosed with diverticulitis; in particular, to evaluate the role of demographic variables on disease course. METHODS Using the Canadian Institute for Health Information Discharge Abstract Databases, readmission rates, length of stay, colectomy rates and mortality rates in patients hospitalized for diverticulitis were examined. Data were stratified according to age, sex and comorbidity (as defined by the Charlson index). RESULTS In the cohort ≤30 years of age, a clear male predominance was apparent. Colectomy rate in the index admission, stratified according to age, demonstrated a J-shaped curve, with the highest rate in patients ≤30 years of age (adjusted OR 2.3 [95% CI 1.62 to 3.27]) compared with the 31 to 40 years of age group. In-hospital mortality increased with age. Cumulative rates of readmission at six and 12 months were 6.8% and 8.8%, respectively. CONCLUSION In the present nationwide cohort study, younger patients (specifically those ≤30 years of age) were at highest risk for colectomy during their index admission for diverticulitis. It is unclear whether this observation was due to more virulent disease among younger patients, or surgeon and patient preferences.
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Nagata N, Niikura R, Aoki T, Shimbo T, Itoh T, Goda Y, Suda R, Yano H, Akiyama J, Yanase M, Mizokami M, Uemura N. Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan. Int J Colorectal Dis 2014; 29:379-85. [PMID: 24317937 DOI: 10.1007/s00384-013-1808-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2013] [Indexed: 02/04/2023]
Abstract
PURPOSES Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years. METHODS Twenty-eight thousand one hundred ninety-two patients who underwent colonoscopy at an emergency hospital were reviewed from an electronic endoscopy database. Diverticula were classified as right-sided, left-sided, and bilateral types, and time trends in the proportion in diverticulosis, type, and diverticular bleeding were determined. Associations of age (≤39, 40-59, and ≥60 years), sex, and year increase with disease and odds ratios were estimated using logistic regression. RESULTS Diverticulosis was identified in 6,150 patients (20.3 %; mean age, 67.6 years) and was predominantly right-sided (48.0 %). Diverticular bleeding was found in 427 (1.5 %; mean age, 69.7 years) and was predominantly bilateral (47.0 %). Proportion of colonic diverticulosis increased significantly (P < 0.01 for trend) from 66.0 % (1,424/2,157) in 2003 to 70.1 % (2,914/4,159) in 2011 and was associated (P < 0.01) with an increased number of patients aged ≥60 years. Proportion of diverticular bleeding increased significantly (P < 0.01 for trend) from 1.02 % (22/2,157) in 2003 to 1.67 % (69/4,159) in 2011 and was associated (P = 0.04) with an increased number of patients aged 40-59 years. Diverticulosis, right and bilateral type, and diverticular bleeding were independently associated with the 9-year trend after adjustment by age and sex. CONCLUSIONS Colonic diverticulosis and diverticular bleeding are prevalent and increasing in Japan. Given the significant association of age with this trend, both diseases can be expected to increase for decades to come.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan,
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Peery AF, Sandler RS. Diverticular disease: reconsidering conventional wisdom. Clin Gastroenterol Hepatol 2013; 11:1532-7. [PMID: 23669306 PMCID: PMC3785555 DOI: 10.1016/j.cgh.2013.04.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/24/2013] [Accepted: 04/24/2013] [Indexed: 02/07/2023]
Abstract
Colonic diverticula are common in developed countries and complications of colonic diverticulosis are responsible for a significant burden of disease. Several recent publications have called into question long-held beliefs about diverticular disease. Contrary to conventional wisdom, studies have not shown that a high-fiber diet protects against asymptomatic diverticulosis. The risk of developing diverticulitis among individuals with diverticulosis is lower than the 10% to 25% proportion that commonly is quoted, and may be as low as 1% over 11 years. Nuts and seeds do not increase the risk of diverticulitis or diverticular bleeding. It is unclear whether diverticulosis, absent diverticulitis, or overt colitis is responsible for chronic gastrointestinal symptoms or worse quality of life. The role of antibiotics in acute diverticulitis has been challenged by a large randomized trial that showed no benefit in selected patients. The decision to perform elective surgery should be made on a case-by-case basis and not routinely after a second episode of diverticulitis, when there has been a complication, or in young people. A colonoscopy should be performed to exclude colon cancer after an attack of acute diverticulitis but may not alter outcomes among individuals who have had a colonoscopy before the attack. Given these surprising findings, it is time to reconsider conventional wisdom about diverticular disease.
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Affiliation(s)
- Anne F. Peery
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Robert S. Sandler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Acute diverticulitis in the young: the same disease in a different patient. Gastroenterol Res Pract 2013; 2013:867961. [PMID: 23554811 PMCID: PMC3608115 DOI: 10.1155/2013/867961] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 02/12/2013] [Indexed: 01/27/2023] Open
Abstract
Background. Natural history and risk factors for diverticulitis in young patients are still debatable. This study aimed to assess whether difference exists in patients aged 50 and younger when compared to older patients and to identify risk factors for acute diverticulitis in the young. Patients and Methods. From January 2006 to December 2011, 80 patients were admitted to our department for acute diverticulitis. We carried out a cross-sectional study in 23 patients (28.7%) aged 50 and younger and 57 older patients (71.3%). Results. Acute diverticulitis in the young was not more aggressive than in the older patient. Diverticulitis at patient's admission was similar with respect to Hinchey's stage and prior history of diverticulitis. No significant difference was found for both medical and surgical treatment. The rate of recurrent diverticulitis in nonoperated patients was similar. Male gender, body mass index ≥25, and assumption of alcohol were independent risk factors for the occurrence of an acute diverticulitis in the young. Conclusions. The same disease seems to be affecting young patients such as overweight or obese male individual. Current policies to prevent diverticular disease and its related complications must include obesity control together with high-fiber diet and regular exercise.
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Annibale B, Lahner E, Maconi G, Usai P, Marchi S, Bassotti G, Barbara G, Cuomo R. Clinical features of symptomatic uncomplicated diverticular disease: a multicenter Italian survey. Int J Colorectal Dis 2012; 27:1151-9. [PMID: 22573184 DOI: 10.1007/s00384-012-1488-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2012] [Indexed: 02/05/2023]
Abstract
PURPOSE Clinical features of symptomatic uncomplicated diverticular disease are poorly investigated. Abdominal symptoms may be similar to those of irritable bowel syndrome. This survey aimed to assess clinical features associated with symptomatic uncomplicated diverticular disease. METHODS This multicenter survey included consecutive outpatients with symptomatic uncomplicated diverticular disease to whom a detailed clinical questionnaire regarding demographic, lifestyle, and clinical features was administered. Diagnosis was based on the presence of diverticula and abdominal pain/discomfort. Irritable bowel syndrome and functional dyspepsia were assessed according to Rome III criteria. RESULTS A total of 598 patients (50 % female, age 69 years), 71 % with newly diagnosed symptomatic uncomplicated diverticular disease and 29 % with history of colonic diverticula, were recruited. Diverticula were localized in the left colon in 78 % of the patients. Recurrent short-lived abdominal pain (<24 h) was present in 70 % (relieved by evacuation in 73 %), prolonged abdominal pain (>24 h) in 27 %, and recurrent abdominal bloating in 61 % of the patients. Normal, loose, or hard stools were reported by 58, 29, and 13 % of patients, respectively. Irritable bowel syndrome (IBS)-like and functional dyspepsia-like symptoms were recorded in 59 and 7 % of patients, respectively. IBS-like symptoms (odds ratio, 4.3) were associated in patients with prolonged abdominal pain. CONCLUSIONS Symptomatic uncomplicated diverticular disease is associated with a gender ratio of 1:1 and an unspecific clinical picture mainly characterized by normal stools, short-lived abdominal pain, abdominal bloating, IBS-like symptoms, while functional dyspepsia-like symptoms are not commonly present. These findings suggest that symptomatic uncomplicated diverticular disease often shows similar findings rather than overlaps IBS.
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Affiliation(s)
- Bruno Annibale
- Department of Digestive and Liver Disease, University Sapienza, Sant'Andrea Hospital, Rome, Italy.
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Abstract
Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.
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Symeonidis N, Psarras K, Lalountas M, Baltatzis M, Micha A, Pavlidis E, Sakantamis A. Clinical features of colonic diverticular disease. Tech Coloproctol 2012; 15 Suppl 1:S5-8. [PMID: 21887570 DOI: 10.1007/s10151-011-0738-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.
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Affiliation(s)
- N Symeonidis
- 2nd Propedeutical Department of Surgery, Medical School, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos str, PC, 54642 Thessaloniki, Greece.
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21
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Kim SY, Oh TH, Seo JY, Jeon TJ, Seo DD, Shin WC, Choi WC, Jeong MJ. The clinical factors for predicting severe diverticulitis in Korea: a comparison with Western countries. Gut Liver 2012; 6:78-85. [PMID: 22375175 PMCID: PMC3286743 DOI: 10.5009/gnl.2012.6.1.78] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 06/20/2011] [Accepted: 07/31/2011] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS It is unclear whether the risk factors associated with complicated diverticulitis in Asian and Western countries are the same. We evaluated the risk factors associated with severe diverticulitis (SD) in Korea and compared the clinical characteristics of diverticulitis according to location. METHODS A retrospective review of 190 patients hospitalized with acute diverticulitis from January 2005 to June 2010 was conducted. SD was defined as one of the following: perforation, abscess, obstruction, sepsis, or peritonitis that required an urgent operation. RESULTS Twenty-four patients (12.6%) were diagnosed with SD. SD was significantly associated with older age, a fever over 38℃, changes in bowel habits and a high visceral adipose tissue (VAT)/total adipose tissue (TAT) ratio. Multivariate analysis showed that the risk factors for developing SD were an age of 40 years or more (odds ratio [OR], 3.2; p=0.032), male gender (OR, 4.0; p=0.021) and left-sided diverticulitis (OR, 6.2; p=0.017). Right-sided diverticulitis (n=175, 92.1%) was significantly associated with younger ages, fewer changes in bowel habits, fewer comorbidities and non-SD. CONCLUSIONS This study suggests that the risk factors for developing SD in Korea, where right-sided diverticulitis is predominant, are the male gender, an age of more than 40 years old, and left-sided diverticulitis. Given that there are different risk factors for developing SD in Western countries, different strategies for the treatment of diverticulitis in the Korean population seem to be needed.
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Affiliation(s)
- Sun Young Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Manwaring M, Champagne B. Diverticular Disease: Genetic, Geographic, and Environmental Aspects. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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23
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Lee Y, Francone T. Special Situations in the Management of Colonic Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Matrana MR, Margolin DA. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 2011; 22:141-6. [PMID: 20676256 DOI: 10.1055/s-0029-1236157] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Diverticular disease is common and thought to result from structural abnormalities of the colonic wall, disordered intestinal motility, or deficiencies of dietary fiber. Signs and symptoms of inflammation include fever, abdominal pain, and leukocytosis.
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Affiliation(s)
- Marc R Matrana
- Internal Medicine, Ochsner Clinic Foundation, New Orleans, Louisiana
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25
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Tan KK, Hong CC, Zhang J, Liu JZ, Sim R. Predictors of outcome following surgery in colonic perforation: an institution's experience over 6 years. J Gastrointest Surg 2011; 15:277-84. [PMID: 20824374 DOI: 10.1007/s11605-010-1330-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 08/11/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Colonic perforation is associated with abysmal outcome. The aims of our study were to review the surgical outcome of patients with perforated colon and to identify factors predicting peri-operative complications. METHODS A retrospective review of all patients who underwent surgery for colonic perforation from January 2003 to August 2008 was performed. Patients with iatrogenic or traumatic perforation were excluded. The severity of abdominal sepsis was graded using the Mannheim peritonitis index (MPI). RESULTS A total of 129 patients, with median age of 65 years (22-97 years), formed the study group. While 29.5% had severe peritoneal contamination, 56.6% had an American Society of Anesthesiologists (ASA) score ≥3. Sigmoid colon (47.3%) and caecum (24.8%) were the most common sites of perforation. Diverticulitis and malignancy were the diagnoses in 51.9% and 34.9%, respectively. Hartmann's procedure and right hemicolectomy were performed in 43.4% and 34.1% of the patients, respectively. Stoma was created in 59.7%. The in-hospital mortality rate in our series was 15.5%. After multivariate analysis, the independent variables associated with worse peri-operative complications were ASA score ≥3, MPI >26 and creation of stoma. Malignant perforation was associated with higher ASA score and lower haematocrit level compared to diverticular perforation. Stoma was created more frequently in patients with MPI >26 and left-sided perforation, and was associated with worse complications. CONCLUSIONS Surgery for colonic perforation is associated with high morbidity and mortality rates. Short-term outcome is determined by ASA score and severity of peritonitis. A lower haematocrit level must alert the possibility of malignancy.
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Affiliation(s)
- Ker-Kan Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
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Feo L, Schaffzin DM. Colonic stents: the modern treatment of colonic obstruction. Adv Ther 2011; 28:73-86. [PMID: 21229339 DOI: 10.1007/s12325-010-0094-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Indexed: 02/06/2023]
Abstract
Colonic stents traditionally have been used for the management of colorectal cancer, either as a palliative treatment or as a bridge to surgery. More recently, colonic stents have also been advocated as part of the therapy of benign strictures. A number of colonic stents are available worldwide, four of which are made in the USA. These stents are classified as covered or uncovered, with similar clinical applications. Technical and clinical success rates are similar among these different stents, as well as the rate of complications, which mainly consist of obstruction and migration. The deployment systems utilize fluoroscopy, endoscopy, or both. More recently, stents became available that are deployed "through the scope" (TTS) making the procedure faster. However, this advance does not exclude the use of fluoroscopy, particularly in those cases where the direct visualization of the proximal end of the stricture is absent. The increasing experience in the management of colorectal cancer with colonic stents decreases the morbidity and mortality, as well as cost, in comparison with surgical intervention for acute colonic obstruction. Management with colonic stents can also rule out proximal synchronous lesions after initial decompression prior to definitive surgery. Benign conditions may also be treated with stents. A multidisciplinary approach for the use of colonic stents during assessment and management of acute colonic obstruction is necessary in order to achieve a satisfactory outcome, whether that be better quality of life or improved survival.
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Affiliation(s)
- Leandro Feo
- Hahnemann University Hospital, Drexel University School of Medicine, Philadelphia, PA, USA
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27
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Pendlimari R, Touzios JG, Azodo IA, Chua HK, Dozois EJ, Cima RR, Larson DW. Short-term outcomes after elective minimally invasive colectomy for diverticulitis. Br J Surg 2010; 98:431-5. [PMID: 21254022 DOI: 10.1002/bjs.7345] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of minimally invasive surgery in complicated diverticulitis is still being elucidated. The aim of this study was to compare short-term outcomes in patients undergoing minimally invasive surgery for complicated or uncomplicated diverticular disease. METHODS All patients who had elective minimally invasive surgery for diverticulitis between 2003 and 2008 were identified from a prospectively maintained database. Complicated disease was defined as diverticulitis associated with abscess, fistula, stricture or bleeding. Univariable analysis was performed to compare safety and short-term outcomes in patients with complicated and uncomplicated diverticulitis. RESULTS A total of 361 patients (136 with complicated and 225 with uncomplicated diverticulitis) were operated on with either a laparoscopic (36·0 per cent) or a hand-assisted laparoscopic (64·0 per cent) surgical technique. There were no significant differences between the groups with respect to age, sex, body mass index, laparoscopic approach, postoperative recovery protocol or previous open surgery. Conversion rates were similar for complicated and uncomplicated disease (14·0 versus 11·6 per cent respectively; P = 0·514). There was no difference between the groups with respect to return of bowel function (mean 3·1 versus 3·2 days respectively; P = 0·156), morbidity (27·9 versus 19·6 per cent; P = 0·070) or mean length of stay (5·4 versus 4·8 days; P = 0·186). There were no deaths within 30 days. CONCLUSION Elective minimally invasive colectomy is feasible for patients with uncomplicated and complicated diverticulitis, with equivalent outcomes.
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Affiliation(s)
- R Pendlimari
- Division of Colon and Rectal Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905, USA
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Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47:680-735. [PMID: 20684920 DOI: 10.1067/j.cpsurg.2010.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jason Hall
- Department of Colon and Rectal Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Hanna T, Akoh JA. Acute presentation of intestinal malrotation in adults: a report of two cases. Ann R Coll Surg Engl 2010; 92:W15-8. [PMID: 20810017 DOI: 10.1308/147870810x12699662981915] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Intestinal malrotation is a rare developmental abnormality occurring as a result of incomplete rotation during fetal life. It usually presents in the first few weeks of life, but may persist unrecognised into adult life. We report two interesting cases in elderly patients both characterised by a significant diagnostic challenge due to atypical clinical and radiological signs and in one case an unusual complication following laparotomy. CASE REPORTS The first case was a 64-year-old man initially treated for diverticulitis but at laparotomy was found to have malrotation of the midgut and a perforated left-sided appendicitis. The second case was a 76-year-old woman admitted with multiple fractures and increasing abdominal distension following a fall. Ten days after admission, she underwent right hemicolectomy to treat faecal peritonitis due to multiple caecal perforations complicating volvulus in the presence of midgut malrotation. CONCLUSIONS These cases illustrate challenges associated with managing patients with undiagnosed intestinal malrotation. Delayed diagnosis is a common feature in several case reports describing atypical presentation of appendicitis in patients with malrotation. While abdominal CT scan can remove much of the diagnostic uncertainty, the diagnosis of malrotation can be missed unless there is a high index of suspicion.
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Affiliation(s)
- Thomas Hanna
- Department of Surgery, Derriford Hospital, Plymouth, UK
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Schaffzin DM, Wong WD. Nonoperative management of complicated diverticular disease. Clin Colon Rectal Surg 2010; 17:169-76. [PMID: 20011272 DOI: 10.1055/s-2004-832698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The complications of diverticular disease of the colon can be divided into those related to inflammatory conditions (diverticular abscess, fistula, and perforation) and those related to noninflammatory conditions (lower gastrointestinal hemorrhage and noninflammatory stricture or obstruction). Nonoperative management of uncomplicated diverticulitis includes bowel rest and antibiotics. For abscesses, percutaneous drainage by radiologic guidance often turns complicated diverticulitis to an uncomplicated condition. In very select instances, fistulas or even perforation may be managed without operation. Strictures may be dilated or stented. Diverticular hemorrhage may be controlled with colonoscopic and angiographic techniques. For colonoscopy, these include cautery, epinephrine injection, and endoclips. For angiography, these include arterial infusion of vasopressin and selective embolization of bleeding vessels. For both diverticulitis and diverticular bleeding, these nonoperative therapeutic modalities may be utilized as a bridge to surgery, or in select instances as a definitive therapy obviating the need for surgery.
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Achiam M, Andersen L, Klein M, Løgager V, Chabanova E, Thomsen H, Rosenberg J. Differentiation between benign and malignant colon tumors using fast dynamic gadolinium-enhanced MR colonography; a feasibility study. Eur J Radiol 2010; 74:e45-50. [DOI: 10.1016/j.ejrad.2009.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 03/10/2009] [Accepted: 03/18/2009] [Indexed: 10/20/2022]
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Keränen I, Lepistö A, Udd M, Halttunen J, Kylänpää L. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45:725-31. [PMID: 20205505 DOI: 10.3109/00365521003663696] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Self-expanding metal stents (SEMS) have been successfully used as a "bridge to surgery" or as palliation for acute malignant colorectal obstruction. Little data on the use of stents for benign obstruction exists and the results vary. The purpose of this study was to evaluate the efficacy and safety of SEMS in benign colorectal obstruction. MATERIAL AND METHODS A total of 21 patients with 23 SEMS procedures between the years 1998 and 2008 were retrospectively studied. Eight patients had an obstruction in the surgical anastomosis. In addition, there were two patients with anastomotic strictures due to Crohn's disease. In 10 patients the obstruction was caused by diverticular disease and one patient had a stricture after radiation therapy. RESULTS Technical success was achieved for all the patients. Clinical success was achieved for 76% (16/21) of the patients. The anastomotic strictures were resolved with SEMS in 5 out of 8 cases (63%). Three patients with diverticular stricture (30%) were eventually resolved with SEMS. Nine (43%) patients in 10 out of 23 procedures (43%) had a complication, the majority being in patients with diverticular stricture. CONCLUSIONS SEMS is a good treatment option for patients with anastomotic stricture of the colon and for patients with benign colonic stricture who are unfit for surgery. SEMS can be used as a bridge to surgery in diverticular obstruction but there seems to be a considerable risk of complications. If a SEMS is placed into a diverticular stricture, the planned bowel resection should be performed within a month.
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Affiliation(s)
- Ilona Keränen
- Department of Gastrointestinal and General Surgery, Meilahti Hospital, HUS, Finland.
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Pommergaard HC, Vilmann P, Jakobsen HL, Achiam MP. A clinical evaluation of endoscopically placed self-expanding metallic stents in patients with acute large bowel obstruction. Scand J Surg 2010; 98:143-7. [PMID: 19919918 DOI: 10.1177/145749690909800303] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Self-expanding metallic stents (SEMS) have since 1991 established themselves as an option in the treatment of large bowel obstruction. The aim of this study was to evaluate the use of SEMS in management of acute colorectal obstructions at a Danish Surgical Gastroenterology center. MATERIAL AND METHODS Retrospective review of charts from all patients who, in the period Marts 2002 to December 2007 underwent insertion of a SEMS for an acute large bowel obstruction. RESULTS Of 45 patients included, SEMS was intended as a bridge to surgery in 20 patients and as palliation in 25 patients. For malignant etiology, the SEMS procedure was a technical and clinical success in 97.4% of the cases. Complications occurred in 21%, mortality rate 2,6%. For benign etiology, the SEMS procedure was a technical success in 85.7%, and a clinical success in 71.4%. Complications occurred in 71.4% of the benign cases with a mortality rate of 28,6%. CONCLUSIONS Placement of SEMS for acute large bowel obstruction with malignant etiology is an effective and safe procedure with low mortality and morbidity. However results for benign obstructions are questionable and more research is needed to determine the role of SEMS.
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Affiliation(s)
- H C Pommergaard
- Department of Surgical Gastroenterology Z, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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Jeyarajah S, Faiz O, Bottle A, Aylin P, Bjarnason I, Tekkis PP, Papagrigoriadis S. Diverticular disease hospital admissions are increasing, with poor outcomes in the elderly and emergency admissions. Aliment Pharmacol Ther 2009; 30:1171-82. [PMID: 19681811 DOI: 10.1111/j.1365-2036.2009.04098.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diverticular disease has a changing disease pattern with limited epidemiological data. AIM To describe diverticular disease admission rates and associated outcomes through national population study. METHODS Data were obtained from the English 'Hospital Episode Statistics' database between 1996 and 2006. Primary outcomes examined were 30-day overall and 1-year mortality, 28-day readmission rates and extended length of stay (LOS) beyond the 75th percentile (median inpatient LOS = 6 days). Multiple logistic regression analysis was used to determine independent predictors of these outcomes. RESULTS Between the study dates 560 281 admissions with a primary diagnosis of diverticular disease were recorded in England. The national admission rate increased from 0.56 to 1.20 per 1000 population/year. 232 047 (41.4%) were inpatient admissions and, of these, 55 519 (23.9%) were elective and 176 528 (76.1%) emergency. Surgery was undertaken in 37 767 (16.3%). The 30-day mortality was 5.1% (n = 6735) and 1-year mortality was 14.5% (n = 11 567). The 28-day readmission rate was 9.6% (n = 21 160). Increasing age, comorbidity and emergency admission were independent predictors of all primary outcomes. CONCLUSIONS Diverticular disease admissions increased over the course of the study. Patients of increasing age, admitted as emergency and significant comorbidity should be identified, allowing management modification to optimize outcomes.
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Affiliation(s)
- S Jeyarajah
- Department of Colorectal Surgery, King's College Hospital, London, UK
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Rees JR, Burgess P. Conservative management of complex diverticular disease causing a retroperitoneal perforation. BMJ Case Rep 2009; 2009:bcr03.2009.1692. [PMID: 21977059 DOI: 10.1136/bcr.03.2009.1692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Diverticular disease is very common and may cause symptoms of psoas irritation because of contiguous inflammation arising from the colon affecting the retroperitoneum. Retroperitoneal perforation is rare and is marked by free gas in the adjacent musculature. Rarely infection and associated gas may track into the lower limbs; however, if adequate drainage can be achieved, surgery in the unfit may be avoided. We present a case of a 79-year-old woman with retroperitoneal perforation of diverticular disease presenting with free gas in the leg musculature that was managed conservatively because of associated comorbidities and was associated with the formation of a cutaneous faecal fistula in the lower limb.
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Affiliation(s)
- Jonathan Richard Rees
- Gloucestershire Royal Hospital, Colorectal Surgery, Great Western Road, Gloucester GL1 3NN, UK
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Abstract
Diverticulosis of the colon is a very common condition. Described as early as the 17th century, most of the information we now have is based on much of the work during the 20th century. Age, sex, race, and geography all play a specific role in the development of diverticula. It is the merging of these factors that changes the prevalence of diverticula and their manifestations. Symptomatic diverticula can lead to serious complications requiring both medical and surgical interventions to treat these complications when they occur. This review will focus on the history and epidemiology of diverticulosis in regard to age, sex, race, geography, and the epidemiology of complicated diverticular disease.
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Affiliation(s)
- Jerry Martel
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Abstract
OBJECTIVE The purpose of our study is to present a series of 14 patients with chronic diverticulitis on barium enema examinations and to correlate the radiographic findings with the clinical and pathologic findings in these patients. CONCLUSION Chronic diverticulitis is a distinct pathologic entity characterized by the frequent development of chronic obstructive symptoms and abdominal pain rather than the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the basis of the characteristic clinical and radiographic findings in these patients.
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Jeyarajah S, Papagrigoriadis S. Diverticular disease increases and effects younger ages: an epidemiological study of 10-year trends. Int J Colorectal Dis 2008; 23:619-27. [PMID: 18274764 DOI: 10.1007/s00384-008-0446-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2008] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Little data exists on epidemiological trends of diverticular disease (DD). This study of 2,979 admissions over 10 years aimed to examine the epidemiological trends of DD admissions and clinical outcomes. METHODS A retrospective analysis of all admissions with DD from 1995 to 2004 was performed. General population data for the area was obtained from the national Census and local primary care trust. RESULTS Annual admissions for DD increased from 71 to 263 (p = 0.000). There was a trend of decreasing mean age from 71.2 years in 1995 to 68.1 in 2004 (p = 0.06). Admissions younger than 50 years increased from eight in 1995 to 42 in 2003 (p = 0.005). The mean age and size of the catchment population remained stable in that time. More emergency admissions underwent surgery (14.4%, n = 54) than electives (6.1%, n = 66) and had longer lengths of stay (25.2 vs. 9.2 days; p = 0.000). More patients under 50 (19.6%, n = 21) had surgery compared with older ones (8.8%, n = 100; p = 0.000). Recurrent admissions increased from 18 to 72 per year (p = 0.000) but were not associated with poor clinical outcomes. There were 21 deaths overall. Deaths were more likely in emergencies (p = 0.000, OR = 56.42) and those aged over 80 (p = 0.000, OR = 2.87). Mortality was independent of co-morbidity and other demographic factors. CONCLUSION DD admissions increased, unexplained by an ageing population, increasingly affecting younger patients who are more likely to undergo surgery, particularly as emergencies. Emergency admissions are associated with longer stay and higher mortality. Recurrent admission cannot be used as guide to elective surgery. Efforts should be made to treat more DD electively.
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Abstract
Lower GI bleeding is a very broad topic, which can encompass situations from a small amount of red blood on tissue paper associated with formed brown stool, to life-threatening severe haemorrhage. Much of the literature on this topic focuses on acute bleeding necessitating hospitalisation and urgent intervention. The literature that is available focuses primarily on medical intervention and support, which will be covered in another review in this series. Causes for lower GI bleeding include diverticular disease, vascular ectasia, ischemic, inflammatory or infectious colitis, colonic neoplasia (including post polypectomy bleeding), anorectal causes (including haemorrhoids, fissures and rectal varices), and small bowel lesions (Crohn's, vascular ectasia, Meckel's diverticula, and small bowel tumours). Different clinical series identified these lesions in varying frequencies. Factors associated with the development of acute lower GI bleeding include advanced age and use of non-steroidal anti-inflammatory medication. Colonoscopy is the single most frequent intervention in evaluating all the patients with lower GI bleeding. Determining the precise impact of colonoscopy on the outcome of lower GI bleeding is difficult due to the retrospective nature of many studies, and the frequent inability to definitively establish the exact bleeding site.
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Affiliation(s)
- Gregory Zuccaro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Lorimer JW, Doumit G. Comorbidity is a major determinant of severity in acute diverticulitis. Am J Surg 2007; 193:681-5. [PMID: 17512276 DOI: 10.1016/j.amjsurg.2006.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Revised: 10/04/2006] [Accepted: 10/04/2006] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute colonic diverticulitis may be simple or very complicated. Not much is understood about what factors determine severity. Answering this question may have therapeutic implications. METHODS A retrospective review was performed consisting of teaching hospital admissions for simple or complicated acute diverticulitis. The intent was to identify characteristics of and differences between the 2 groups. The Charlson index was used to assess states of preexisting health (comorbidity). RESULTS In multivariate analysis, the presence of a major degree of comorbidity (Charlson score 3 or greater) was strongly associated with complicated disease (P = 0.02) as was the use of nonsteroidal anti-inflammatory drugs (P = .01). Deaths were not seen below age 50, and high Charlson score also strongly predicted mortality (P < .0001). CONCLUSIONS There are significant differences between patients presenting with simple and complicated diverticulitis, and the amount of associated comorbidity (as measured by Charlson score) appears to be a major one. Because of the high mortality seen in patients with Charlson scores 3 or greater and complicated diverticulitis, we believe that an early surgical approach should be considered for them, particularly if they are 50 or older.
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Affiliation(s)
- John W Lorimer
- Department of Surgery, University of Ottawa, Room K-11, Ottawa Hospital/General Site, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6.
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Laurell H, Hansson LE, Gunnarsson U. Acute diverticulitis--clinical presentation and differential diagnostics. Colorectal Dis 2007; 9:496-501; discussion 501-2. [PMID: 17573742 DOI: 10.1111/j.1463-1318.2006.01162.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To describe the clinical presentation of acute diverticulitis in an emergency department and to characterize the natural history of diverticulitis in the short perspective. Comparisons are made with an important differential diagnosis, nonspecific abdominal pain (NSAP). METHOD Patients admitted to our hospital with abdominal pain of up to 7 days' duration were registered prospectively using a detailed schedule for history, symptoms and signs, from 1 February 1997 to 1 June 2000. Of 3349 patients initially included, 3073 (92%) were eligible for follow up after 1-3 years. RESULTS Acute diverticulitis was the final diagnosis in 145 patients and NSAP in 1142 patients. The incidence of hospitalized patients with diverticulitis was 47 per year and 100 000 population, with a mean hospital stay of 3.3 days. Patients with diverticulitis, more frequently than NSAP, had a longer history and laboratory signs of inflammatory activity. Isolated left abdominal tenderness was more common in diverticulitis, whereas isolated right abdominal tenderness was more common in NSAP. Duration of symptoms on arrival was independent of age and was not correlated to C-reactive protein, leucocytes or body temperature. Sensitivity of diverticulitis as primary diagnosis was 64% and specificity 97%. Corresponding figures for NSAP were 43% and 90% respectively. Age and gender did not influence diagnostic accuracy or risk of surgery. CONCLUSION Diverticulitis differs significantly from NSAP in clinical presentation and laboratory parameters. Sensitivity of primary diagnosis for diverticulitis and NSAP was low.
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Affiliation(s)
- H Laurell
- Department of Surgery at Mora Hospital, Mora, Sweden.
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Hassan I, Cima RR, Larson DW, Dozois EJ, O'Byrne MM, Larson DR, Pemberton JH. The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes. Surg Endosc 2007; 21:1690-4. [PMID: 17593455 DOI: 10.1007/s00464-007-9413-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 03/01/2007] [Accepted: 03/14/2007] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease. METHODS Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture. RESULTS The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70). CONCLUSIONS A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure.
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Affiliation(s)
- Imran Hassan
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Person B, Cera SM, Sands DR, Weiss EG, Vernava AM, Nogueras JJ, Wexner SD. Do elderly patients benefit from laparoscopic colorectal surgery? Surg Endosc 2007; 22:401-5. [PMID: 17522918 DOI: 10.1007/s00464-007-9412-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 03/26/2007] [Accepted: 04/04/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients. AIM To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP). METHODS A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age >or= 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality. RESULTS 641 patients (M/F - 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 - 60%) than in group B (106/234 - 45%) - p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3-17) days versus 8.7 (4-22) days in group B (p <0.0001), and LAP: 5.3 (2-19) days versus 6.4 (2-34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003). CONCLUSIONS Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age.
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Affiliation(s)
- B Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
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de Vries L, Knoepfli AS, Konstantinidis P, Charbonney E. Subcutaneous emphysema: a rare manifestation of a perforated diverticulitis in a patent inguinal canal. Hernia 2006; 11:261-3. [PMID: 17136307 DOI: 10.1007/s10029-006-0172-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Accepted: 11/09/2006] [Indexed: 10/23/2022]
Abstract
Patients with complicated diverticulitis rarely present with extraperitoneal manifestations but the manifestation of subcutaneous emphysema appears even more seldom. We present the case of a patient with a history of diabetes and immunosuppression, who was admitted with sepsis in association with cellulitis and subcutaneous emphysema of the left groin. The absence of peritonism due to corticosteroid treatment, a history of a recent fall with an ilio- and ischio-pubic fracture and subcutaneous emphysema led to a delay in the diagnosis. The final diagnosis was a perforated diverticulitis in a patent inguinal canal, which was only revealed after surgery. The various complications of diverticulitis, including extraperitoneal manifestations, and associated microorganisms implicated in cellulitis and subcutaneous emphysema are briefly reviewed.
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MESH Headings
- Aged, 80 and over
- Colectomy/methods
- Colon, Sigmoid
- Diagnosis, Differential
- Diverticulitis, Colonic/complications
- Diverticulitis, Colonic/diagnosis
- Diverticulitis, Colonic/surgery
- Fatal Outcome
- Female
- Hernia, Inguinal/complications
- Hernia, Inguinal/diagnosis
- Hernia, Inguinal/surgery
- Humans
- Inguinal Canal
- Laparotomy
- Palpation
- Rupture, Spontaneous
- Subcutaneous Emphysema/diagnosis
- Subcutaneous Emphysema/etiology
- Tomography, X-Ray Computed
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Affiliation(s)
- Lambert de Vries
- Internal Medicine Department, University Hospital Geneva, Rue Micheli-Du-Crest 24, 1211, Geneva 14, Switzerland
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Zaidi E, Daly B. CT and clinical features of acute diverticulitis in an urban U.S. population: rising frequency in young, obese adults. AJR Am J Roentgenol 2006; 187:689-94. [PMID: 16928931 DOI: 10.2214/ajr.05.0033] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE On the basis of our experience in recent years, we hypothesized that acute diverticulitis occurs more frequently in young adult patients (age, < or = 50 years) now than previously recognized. We reviewed the CT findings, clinical features, and demographic data of a cohort of patients who presented with acute diverticulitis at an urban U.S. academic medical center. MATERIALS AND METHODS We used our hospital and radiology databases to identify 104 adult patients with both CT and clinical diagnoses of acute diverticulitis. Clinical parameters recorded included age, sex, ethnicity, in- or outpatient management, and therapy (medical treatment, percutaneous drainage, or surgery). CT studies were evaluated for the site of diverticulitis; associated complications; and the presence of abdominal obesity, as determined by measurement of sagittal abdominal diameter. RESULTS The study group was composed of 55 men and 49 women (age range, 22-88 years; mean age, 52.2 years; median age, 49.0 years). Fifty-six (53.8%) were 50 years old or younger, and 22 were 40 years old or younger. Forty-one complications were noted in 38 patients (36%). There was no significant age difference between the < or = 50 and > 50 years old age groups for hospital admission (90 patients, 86.5%), medical therapy (76, 73.1%), or surgery or percutaneous abscess drainage (28, 26.9%). Abdominal obesity measured by sagittal abdominal diameter was present in 48 (85.7%) and 37 (77%) of the < or = 50 and > 50 years old age groups, respectively. The mean sagittal abdominal diameter for patients < or = 50 years old (27.0 cm) was greater than that for patients > 50 years old (25.6 cm) (p = 0.05). CONCLUSION In this urban population, acute diverticulitis occurred more frequently in patients 20-50 years old than previously recognized. This group had significantly greater abdominal obesity than the older group. Severe disease requiring hospital admission, surgery, or percutaneous drainage (or both surgery and percutaneous drainage) was common in all age groups.
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Affiliation(s)
- Eram Zaidi
- Department of Radiology, University of Maryland Medical Center, 22 S Greene St., Baltimore, MD 21201-1595, USA
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Abstract
In Western countries the prevalence of diverticular disease has increased over the past century. Although, most patients remain asymptomatic, among those who experience an attack of diverticulitis, one-third will have recurrent symptoms, and a further third will have a subsequent episode. The indications for surgery after treatment of acute diverticulitis is still under debate. Uncomplicated disease less commonly as thought, progresses to a life threatening situation such as free perforation. Among those who develop complicated diverticulitis, it is often their first presentation. Fistula to the urinary tract often require surgery; however, complicated disease such as an abscess or phlegmon can be managed conservatively and subsequent surgery is selective depending on the recovery from the initial episode. Patients with chronic diverticular disease (persistent pain in the absence of inflammation) have greatly improved quality of life with surgery. The question of greater virulence of disease among young patients may no longer be true and recommendations for surgery may parallel that of older patients. Immunocompromised patients should have definitive surgical therapy early on in the course of the disease. Right-sided disease remains uncommon in the Western world and a conservative approach in the absence of free perforation is recommended. In right-sided disease and in young patients, misdiagnosis is common. In the elective setting, a laparoscopic approach is rapidly becoming preferred because of less morbidity and shorter hospital stay. The treatment of diverticular disease is rapidly undergoing reevaluation, and novel therapies and increased conservative approaches are evolving. Prospective randomized trials are needed, but remain difficult owing to the uncertain natural history of the disease.
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Affiliation(s)
- Jared Frattini
- Department of Surgery, Section of Gastrointestinal Surgery, Yale University School of Medicine, New Haven, CT 06510, USA
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Tandon T, Moss MC, Shaik M, Jadhav A, Goyal S. Perforated colonic diverticulum presenting as necrotizing fasciitis of the thigh. J Orthop Sci 2005; 10:534-6. [PMID: 16193368 DOI: 10.1007/s00776-005-0926-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2004] [Accepted: 05/09/2005] [Indexed: 01/07/2023]
Affiliation(s)
- Tarang Tandon
- Department of Orthopaedics, St Richards Hospital, Chichester, West Sussex, PO19 6SE, UK
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Killingback M, Barron PE, Dent OF. Elective surgery for diverticular disease: an audit of surgical pathology and treatment. ANZ J Surg 2005; 74:530-6. [PMID: 15230784 DOI: 10.1111/j.1445-2197.2004.03071.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a need for a better classification of the surgical pathology of diverticular disease treated by elective resection. METHODS A prospective audit was conducted over a 25-year period, during which the surgeon studied the surgical pathology. The results of surgical treatment have been related to the pathology. RESULTS Two hundred and six patients were managed by elective resection with a postoperative mortality of 1.0% and a total morbidity of 51.5%. The surgical pathology was classified as: non-inflammatory 25 (12.6%), localized diverticulitis 90 (43.7%) and extracolic diverticulitis 90 (44.2%). CONCLUSIONS This classification is useful to relate the technical requirements of surgery and the outcome to the surgical pathology. Postoperative morbidity is associated with the presence and severity of inflammatory pathology and therefore the casemix of any series will have a significant impact on this aspect.
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Buckley O, Geoghegan T, O'Riordain DS, Lyburn ID, Torreggiani WC. Computed tomography in the imaging of colonic diverticulitis. Clin Radiol 2004; 59:977-83. [PMID: 15488845 DOI: 10.1016/j.crad.2004.05.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2003] [Revised: 04/13/2004] [Accepted: 05/04/2004] [Indexed: 02/08/2023]
Abstract
Colonic diverticulitis occurs when diverticula within the colon become infected or inflamed. It is becoming an increasingly common cause for hospital admission, particularly in western society, where it is linked to a low fibre diet. Symptoms of diverticulitis include abdominal pain, diarrhoea and pyrexia, however, symptoms are often non-specific and the clinical diagnosis may be difficult. In addition, elderly patients and those taking corticosteroids may have limited findings on physical examination, even in the presence of severe diverticulitis. A high index of suspicion is required in such patients in order to avoid a significant delay in arriving at the correct diagnosis. Imaging plays an important role in establishing an early and correct diagnosis. In the past, contrast enema studies were the principal imaging test used to make the diagnosis. However, such studies lack sensitivity and have limited success in identifying abscesses that may require drainage. Conversely computed tomography (CT) is both sensitive and specific in making a diagnosis of diverticulitis. In addition, it is the imaging technique of choice in depicting complications such as perforation, abscess formation and fistulae. CT-guided drainage of diverticular abscesses helps to reduce sepsis and to permit a one-stage, rather than two-stage, surgical operation. The purpose of this review article is to discuss the role of CT in the imaging of diverticulitis, describe the CT imaging features and complications of this disease, as well as review the impact and rationale of CT imaging and intervention in the overall management of patients with diverticulitis.
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Affiliation(s)
- O Buckley
- Department of Surgery, Adelaide and Meath Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland
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