Elective Laparoscopic Sigmoid Colectomy for Diverticulitis-an Updated Look at Recurrence After Surgery

Diverticulitis in Older Adults: A Review of Etiology, Diagnosis, and Management

BACKGROUND

Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care.

METHODS AND RESULTS

We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment.

CONCLUSIONS

Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.

Long-term Follow-up After an Initial Episode of Diverticulitis: A 13-Year Update

BACKGROUND

For patients with recurrent diverticulitis, the trigger to proceed to elective sigmoid colectomy is unclear. Current clinical practice guidelines suggest that this is an individualized decision between surgeon and patient.

OBJECTIVE

To assess the long-term risk of diverticulitis recurrence and determine predictors of recurrent disease.

DESIGN

Retrospective case series.

SETTING

Tertiary care center.

PATIENTS

Consecutive patients with CT-proven diverticulitis who presented as inpatient or outpatient between 2002 and 2008.

INTERVENTIONS

Incidence of diverticulitis recurrence was determined via medical record review and questionnaire.

MAIN OUTCOME MEASURES

Risk of recurrent diverticulitis or surgery for diverticulitis.

RESULTS

A total of 753 patients with first-time diverticulitis were identified. The patients had a mean age of 61.5 years (SD 15.3). The median follow-up was 13.2 years (interquartile range, 3.8-18.3). There were 486 patients (64.5%) alive at the time of follow-up. During the initial presentation, 29 patients (3.9%) required Interventional Radiology drainage and 37 (4.9%) required emergency surgery. Forty-three patients (5.7%) underwent elective surgery after the initial presentation and 77 (10.2%) underwent surgery after more than 1 episode. Of those who did not undergo surgery for the first episode, 353 (52.4%) experienced recurrent disease with a median time to recurrence of 2.9 years (interquartile range, 0.83-8.5 years). On multivariate analysis, female sex (HR 1.28, p = 0.04), sigmoid disease (HR 1.35, p = 0.03), smoldering disease (HR 3.17, p < 0.01), length of involved segment >5 cm (HR 1.28, p = 0.04), and maximum fat stranding diameter >1.8 cm (HR 1.29, p = 0.03) were associated with disease recurrence. Kaplan-Meier estimates of freedom from recurrence were 73.1% (69.6%-76.3%) at 1 year, 47.9% (44.0%-51.6%) at 5 years, and 34.6% (31.0%-38.2%) at 10 years after initial presentation.

LIMITATIONS

Retrospective design.

CONCLUSIONS

After a single episode of diverticulitis, the incidence of recurrence is more than 50% on long-term follow-up. Variables such as female sex, sigmoid disease, smoldering disease, length of involved segment >5 cm, and maximum fat stranding diameter >1.8 cm were associated with an increased risk of recurrence. These findings should be considered when counseling patients on the decision to proceed with elective colectomy. See Video Abstract .

SEGUIMIENTO A LARGO PLAZO TRAS UN EPISODIO INICIAL DE DIVERTICULITIS UNA ACTUALIZACIN DE AOS

ANTECEDENTES:En el caso de los pacientes con diverticulitis recurrente, no está claro el factor desencadenante para proceder a una colectomía sigmoidea electiva. Las guías de práctica clínica actuales sugieren que se trata de una decisión individualizada entre el cirujano y el paciente.OBJETIVO:Evaluar el riesgo a largo plazo de recurrencia de la diverticulitis y determinar los predictores de la enfermedad recurrente.DISEÑO:Serie de casos retrospectiva.ESCENARIO:Centro de atención terciaria.PACIENTES:Pacientes consecutivos con diverticulitis comprobada por TC que se presentaron como pacientes hospitalizados o ambulatorios entre 2002 y 2008.INTERVENCIONES:Incidencia de recurrencia de la diverticulitis determinada mediante revisión de historias clínicas y cuestionario.MEDIDAS PRINCIPALES DE RESULTADOS:Riesgo de diverticulitis recurrente o cirugía para diverticulitis.RESULTADOS:Se identificaron 753 pacientes con diverticulitis por primera vez. Los pacientes tenían 61,5 años (DE 15,3). La mediana de seguimiento fue de 13,2 años (RIC 3,8-18,3). 486 (64,5 %) estaban vivos en el momento del seguimiento. Durante la presentación inicial, 29 (3,9 %) requirieron drenaje de IR y 37 (4,9 %) requirieron cirugía de emergencia. 43 (5,7 %) se sometieron a cirugía electiva después de la presentación inicial y 77 (10,2 %) se sometieron a cirugía después de más de 1 episodio. De aquellos sin cirugía para el primer episodio, 353 (52,4 %) experimentaron enfermedad recurrente con un tiempo medio hasta la recurrencia de 2,9 años (RIC 0,83-8,5 años). En el análisis multivariable, el sexo femenino (HR 1,28, p = 0,04), la enfermedad sigmoidea (HR 1,35, p = 0,03), la enfermedad latente (HR 3,17, p < 0,01), la longitud del segmento afectado > 5 cm (HR 1,28, p = 0,04) y el diámetro máximo de la hebra grasa > 1,8 cm (HR 1,29, p = 0,03) se asociaron con la recurrencia de la enfermedad. Las estimaciones de Kaplan Meier de la libertad de recurrencia fueron del 73,1 % (69,6-76,3 %) al año, del 47,9 % (44,0-51,6 %) a los 5 años y del 34,6 % (31,0-38,2 %) a los 10 años después de la presentación inicial.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:Después de un único episodio de diverticulitis, la incidencia de recurrencia es superior al 50% en el seguimiento a largo plazo. Variables como el sexo femenino, la enfermedad sigmoidea, la enfermedad latente, la longitud del segmento afectado mayor de 5 cm y el diámetro máximo de la hebra de grasa mayor de 1,8 cm se asociaron con un mayor riesgo de recurrencia. Estos hallazgos deben tenerse en cuenta al asesorar a los pacientes sobre la decisión de proceder con la colectomía electiva. (Traducción-Yesenia Rojas-Khalil ).

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Association Between Family History and Diverticulitis Recurrence: A Population-Based Study

BACKGROUND

After initial nonoperative management of diverticulitis, individuals with a family history of diverticulitis may have increased risk of recurrent disease.

OBJECTIVE

This study measured the association between family history and recurrent diverticulitis in a population-based cohort.

DESIGN

This is a retrospective, population-based cohort study.

SETTINGS

The cohort was identified from the Utah Population Database, a statewide resource linking hospital and genealogy records.

PATIENTS

Individuals evaluated in an emergency department or hospitalized between 1998 and 2018 for nonoperatively managed diverticulitis were included.

INTERVENTION

The primary predictor was a positive family history of diverticulitis, defined as diverticulitis in a first-, second-, or third-degree relative.

MAIN OUTCOME MEASURES

This study measured the adjusted association between family history and the primary outcome of recurrent diverticulitis. A secondary outcome was elective surgery for diverticulitis. Additional analyses evaluated risk by degree of relation of the affected family member.

RESULTS

The cohort included 4426 individuals followed for a median of 71 months. Median age was 64 years and 45% were male; 17% had complicated disease, 11% had recurrence, and 15% underwent elective surgery. After adjustment, individuals with a family history of diverticulitis had a similar risk of recurrence when compared to those without a family history (HR 1.0; 95% CI 0.8-1.2). However, individuals with a family history of diverticulitis were more likely to undergo elective surgery (HR 1.4; 95% CI 1.1-1.6). This effect was most pronounced in those with an affected first-degree family member (HR 1.7; 95% CI 1.4-2.2).

LIMITATIONS

The use of state-specific data may limit generalizability.

CONCLUSIONS

In this population-based analysis, individuals with a family history of diverticulitis were more likely to undergo elective surgery than those without a family history, despite similar risks of recurrence and complicated diverticulitis. Further work is necessary to understand the complex social, environmental, and genetic factors that influence diverticulitis treatment and outcomes. See Video Abstract at http://links.lww.com/DCR/B876 .

ASOCIACIN ENTRE LOS ANTECEDENTES FAMILIARES Y LA RECURRENCIA DE LA DIVERTICULITIS UN ESTUDIO POBLACIONAL

ANTECEDENTES:Después del tratamiento inicial no quirúrgico de la diverticulitis, las personas con antecedentes familiares de diverticulitis pueden tener un mayor riesgo de enfermedad recurrente.OBJETIVO:Este estudio midió la asociación entre antecedentes familiares y diverticulitis recurrente en una cohorte poblacional.DISEÑO:Este es un estudio de cohorte retrospectivo de la población.ENTORNO CLÍNICO:La cohorte se identificó a partir de la Base de datos de población de Utah, un recurso estatal que vincula los registros hospitalarios y genealógicos.PACIENTES:Se incluyeron individuos evaluados en un departamento de emergencias u hospitalizados entre 1998 y 2018 por diverticulitis manejada de forma no quirúrgica.INTERVENCIÓN:El predictor principal fue un historial familiar positivo de diverticulitis, definida como diverticulitis en un familiar de primer, segundo o tercer grado.PRINCIPALES MEDIDAS DE VALORACIÓN:Este estudio midió la asociación ajustada entre los antecedentes familiares y el resultado primario de diverticulitis recurrente. Un resultado secundario fue la cirugía electiva por diverticulitis. Análisis adicionales evaluaron el riesgo por grado de parentesco del familiar afectado.RESULTADOS:La cohorte incluyó a 4.426 individuos seguidos durante una mediana de 71 meses. La mediana de edad fue de 64 años y el 45% eran varones. El 17% tenía enfermedad complicada, el 11% recidiva y el 15% se sometió a cirugía electiva. Después del ajuste, los individuos con antecedentes familiares de diverticulitis tenían un riesgo similar de recurrencia en comparación con aquellos sin antecedentes familiares (HR 1,0; IC del 95%: 0,8-1,2). Sin embargo, las personas con antecedentes familiares de diverticulitis tenían más probabilidades de someterse a una cirugía electiva (HR 1,4; IC del 95%: 1,1-1,6). Este efecto fue más pronunciado en aquellos con un familiar de primer grado afectado (HR 1,7; IC del 95%: 1,4-2,2).LIMITACIONES:El uso de datos específicos del estado puede limitar la generalización.CONCLUSIONES:En este análisis poblacional, los individuos con antecedentes familiares de diverticulitis tenían más probabilidades de someterse a una cirugía electiva que aquellos sin antecedentes familiares, a pesar de riesgos similares de recurrencia y diverticulitis complicada. Es necesario seguir trabajando para comprender los complejos factores sociales, ambientales y genéticos que influyen en el tratamiento y los resultados de la diverticulitis. Consulte Video Resumen en http://links.lww.com/DCR/B876 . (Traducción-Dr. Ingrid Melo ).

Recurrence of diverticulitis after prophylactic sigmoidectomy: an underestimated problem?

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Recurrent diverticulitis after elective surgery

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of Life After Elective Laparoscopic Sigmoidectomy for Symptomatic Uncomplicated Diverticular Disease

INTRODUCTION

Symptomatic uncomplicated diverticular disease (SUDD) is characterized by abdominal pain and altered bowel function and may affect quality of life. When symptoms are severe and conservative therapy is ineffective, surgical intervention becomes an option.

OBJECTIVE

This study aims to investigate quality of life after elective sigmoidectomy for patients affected by SUDD.

MATERIALS AND METHODS

Retrospective multicenter review of consecutive patients affected by SUDD that underwent elective laparoscopic sigmoidectomy from January 2015 to March 2018. SUDD was defined as the presence of diverticula with persistent localized pain and diarrhea or constipation without macroscopic inflammation. Quality of life was investigated using the Gastrointestinal Quality of Life Index questionnaire at baseline, and at 6 and 12 months after surgery. Readmissions, unplanned clinical examination, mesalazine resumption, and emergency department visit for abdominal symptoms were recorded.

RESULTS

Fifty-two patients were included in the analysis. Gastrointestinal Quality of Life Index score at 6 months from surgery did not statistically differ from baseline (96±10.2 vs. 89±11.2; P>0.05), while patients reported a better quality of life at 12 months after surgery (109±8.6; P<0.05). Within the first year of follow-up, 3 patients (5.8%) were readmitted for acute enteritis, 8 patients (15.4%) had emergency room access for abdominal pain, and 8 patients had unplanned outpatients' medical examinations for referred lower abdominal pain and bowel changes. Mesalazine was resumed in 17.3% of patients.

CONCLUSION

Elective laparoscopic sigmoidectomy for SUDD is safe and effective in improving quality of life, although in some cases symptoms may persist.