Long-term outcomes of sigmoid diverticulitis: a single-center experience

Reoperation and mortality following elective surgery for chronic and recurrent colonic diverticular disease: A nationwide population-based cohort study

PURPOSE

The ideal treatment for chronic and recurrent colonic diverticular disease (crDD) remains unresolved, partly due to lacking evidence regarding surgical safety. This study evaluated 90-day reoperation and mortality rates following elective surgery for crDD and explored predictors for reoperation and mortality.

METHODS

This national cohort study included all patients with crDD undergoing elective colonic resection or stoma formation in Denmark from 1996-2021. Outcomes were the 90-day cumulative incidence proportion (CIP) of reoperation and mortality, and predictors were explored in Cox proportional hazard models.

RESULTS

Among 35,174 patients with crDD, 3,584 (10%) underwent elective surgery. The 90-day reoperation rate was 18.0%; mortality was 1.6%. During the 25-year period, the reoperation rate declined 30%, from 19.5% to 13.8%, and mortality declined 74%, from 2.7% to 0.7%. Among 2,942 patients with colonic resection and no stoma formation, the reoperation rate due to anastomotic leak was 3.0% overall and 0.9% in the most recent years. Mortality was 18 times higher in patients aged ≥ 80 years versus those aged < 60 years (CIP 8.0% versus 0.4%). The reoperation rate was increased in patients with ≥ 4 hospital contacts or ≥ 3 admissions compared to patients with fewer contacts, while mortality was not associated with the number of hospital contacts before surgery.

CONCLUSION

Elective surgery in crDD was safe with careful patient selection. The risk of reoperation due to anastomotic leak was very low. Patients with most hospital contacts had an increased reoperation rate, supporting consideration for elective surgery early in patients with disabling diverticular disease.

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 ).

The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis

Background

There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.

Methods

A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.

Results

Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8–13%, I² = 86%, p < 0.01) in right-sided and 20% (95% CI 16–24%, I² = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6–13%, I² = 77%, p < 0.01) in right-sided and 15% (95% CI 8–27%, I² = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2–10%, I² = 84%, p < 0.01) in right-sided and 4% (95% CI 2–7%, I² = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.

Conclusion

Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.

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.

The Indications for and Timing of Surgery for Diverticular Disease

BACKGROUND

Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease.

METHODS

This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease.

RESULTS

Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails.

CONCLUSION

The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

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.

Recent advances in understanding and managing diverticulitis

In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.