Diverticular disease in Scotland: 2000-2010

National Trends in Hospital Admissions, Interventions, and Outcomes for Early-Onset (Age <50 years) Diverticulitis From 2005 to 2020

BACKGROUND

Little is known about the burden and outcomes of diverticulitis in patients younger than 50 years. This knowledge gap hinders the development of effective management strategies and preventive measures for this population.

OBJECTIVE

This study aimed to analyze national trends in hospitalizations, interventions, and outcomes for early-onset diverticulitis (age younger than 50 years) in comparison to standard-onset diverticulitis (age 50 years or older) cohorts.

DESIGN

Retrospective cohort study.

SETTINGS

A survey-weighted, national sample extracted from the National Inpatient Sample.

PATIENTS

All adults (18 years or older) hospitalized for diverticulitis between 2005 and 2020 were included.

MAIN OUTCOME MEASURES

National trends in the proportions of early-onset versus standard-onset diverticulitis were found to be related, along with the rates of colectomy.

RESULTS

From 2005 to 2020, 5,239,735 patients were nonelectively hospitalized for diverticulitis. Of them, 837,195 (16.0%) were early onset. During the study period, the proportion of the early-onset cohort admitted for complicated diverticulitis significantly increased from 18.5% to 28.2% (nonparametric trend < 0.001). In addition, there was a decline in the proportion of early-onset diverticulitis patients needing a colectomy (34.7%-20.3%, nonparametric trend < 0.001), with a corresponding increase in the proportion of patients needing interventional radiology intervention (12.7%-28.6%, nonparametric trend < 0.001). Compared to standard-onset diverticulitis, early-onset diverticulitis was associated with decreased odds of mortality (adjusted OR 0.18; 95% CI, 0.16-0.20; p < 0.001) as well as decreased length of stay (β -0.28 days; 95% CI, -0.32 to -0.24; p < 0.001) and hospitalization costs (β -$1900; 95% CI, -$2100 to -$1800; p < 0.001). In addition, early-onset diverticulitis was associated with increased odds of colectomy (adjusted OR 1.29; 95% CI, 1.26-1.31) and percutaneous drainage (adjusted OR 1.58; 95% CI, 1.53-1.62).

LIMITATIONS

Retrospective data collection. Lack of granular clinical data.

CONCLUSIONS

There has been a significant increase in the proportion of complicated diverticulitis-related admissions among patients younger than 50 years. Patients with early-onset diverticulitis were more likely to undergo colectomy or percutaneous drainage than those with standard-onset (at age 50 years or older) diverticulitis. Additional research is needed to determine the cause of these trends and identify public health policies aimed at potentially preventing the increasing burden of diverticulitis among younger populations. See Video Abstract .

TENDENCIAS NACIONALES EN ADMISIONES HOSPITALARIAS, INTERVENCIONES Y RESULTADOS EN CASOS DE DIVERTICULITIS PRECOZ EDAD DE A

ANTECEDENTES:Se sabe poco sobre el coste y los resultados de la diverticulitis en pacientes menores de 50 años. Esta falta de conocimientos dificulta el desarrollo de estrategias en el manejo y las medidas preventivas efectivas para esta población.OBJETIVO:Nuestro estudio tiene como objetivo el analizar las tendencias nacionales de las hospitalizaciones, las intervenciones y los resultados en casos de diverticulitis de inicio precoz (edad <50) en comparación con cohortes de inicio estándar (edad ≥50).DISEÑO:Estudio de cohortes de tipo retrospectivo.PARÁMETROS:Muestreo nacional ponderado por encuesta, extraído de la Muestra Nacional de Pacientes Hospitalizados.PACIENTES:Todos los adultos (≥ 18 años) hospitalizados por diverticulitis entre 2005 y 2020.PRINCIPALES MEDIDAS DE RESULTADOS:Tendencias nacionales en las proporciones de diverticulitis precoz frente a diverticulitis de inicio estándar, junto con las tasas de colectomía.RESULTADOS:Entre 2005 y 2020, 5'239.735 pacientes fueron hospitalizados de forma electiva por diverticulitis aguda. 837.195 (16,0%) fueron de inicio temprano. Durante el período de estudio, la proporción de la cohorte de inicio temprano ingresada por diverticulitis complicada aumentó significativamente del 18,5% al 28,2% (nptrend<0,001). Además, hubo una disminución en la proporción de pacientes con diverticulitis de inicio precoz que necesitaron una colectomía (34,7% a 20,3%, nptrend<0,001), con un aumento correspondiente en la proporción de pacientes que necesitaron tratamiento por radiología intervencionista (12,7% a 28,6%, nptrend<0,001). En comparación con la diverticulitis de inicio estándar, la diverticulitis de inicio precoz se asoció con menores probabilidades de mortalidad (odds ratio ajustado [AOR] 0,18, intervalo de confianza del 95 % [IC del 95 %] 0,16-0,20, p < 0,001), así como con una menor duración de la hospitalización (β -0,28 días, IC del 95 % [-0,32, -0,24], p < 0,001) y menores costos de hospitalización (β -$1900, IC del 95 % [-$2100, -$1800], p < 0,001). Además, la diverticulitis de aparición temprana se asoció con mayores probabilidades de colectomía (AOR 1,29, IC del 95 % 1,26-1,31) y de drenaje percutáneo (AOR 1,58, IC del 95 % 1,53-1,62).LIMITACIONES:Recopilación de datos de tipo retrospectivo. Falta de datos clínicos granulares.CONCLUSIÓN:Ha habido un aumento significativo en la proporción de admisiones relacionadas con diverticulitis complicada entre pacientes menores de 50 años. Los pacientes con diverticulitis de aparición precoz tienen más probabilidades de someterse a colectomía o drenaje percutáneo que aquellos con diverticulitis de aparición estándar (>50 años). Se necesitan trabajos futuros para determinar la causa de estas tendencias e identificar políticas de salud pública dirigidas a prevenir potencialmente la creciente carga de diverticulitis entre las poblaciones más jóvenes. (Traducción-Dr. Xavier Delgadillo ).

Rifaximin in diverticulosis and diverticular disease: a national survey among Italian gastroenterologists and general practitioners

The management of patients with diverticular disease remains challenging. The aim of this national survey was to assess how gastroenterologists and general practitioners use rifaximin to manage diverticulosis and diverticular disease. Members of the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Federation of General Practitioners (FIMMG) were invited to complete a 39-item online survey concerning the use of rifaximin in five clinical settings: (1) diverticulosis; (2) reducing symptoms in symptomatic uncomplicated diverticular disease; (3) reducing the occurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (primary prevention); (4) reducing the recurrence of diverticulitis in patients with previous attacks of diverticulitis (secondary prevention); (5) treatment of uncomplicated acute diverticulitis. A total of 1094 physicians completed the survey. Overall, 25.1%, 83.5%, 68%, 74.2%, and 63% of physicians prescribed rifaximin for the clinical settings 1, 2, 3, 4, and 5, respectively. In each clinical setting, the dosage of rifaximin most frequently used was 800 mg/day, the most common duration of therapy was 7 days, and the cyclic administration of treatment (expressed in months) most frequently used was > 24 months. These results highlight that a reappraisal of the use of rifaximin in patients with diverticulosis and diverticular disease is required to reduce the gap between the evidence available and the daily clinical practice, optimizing also the use of healthcare resources.

Conservative management of complicated colonic diverticulitis: long-term results

BACKGROUND

The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease.

AIM

To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis.

METHODS

This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis.

RESULTS

We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05).

CONCLUSIONS

Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

Patients with Diverticular Disease Have Different Dietary Habits Compared to Control Subjects: Results from an Observational Italian Study

The role of dietary habits as risk factor for the development of diverticular complications has strongly emerged in the last years. We aimed to evaluate possible differences in dietary habits between patients with diverticular disease (DD) and matched controls without diverticula. Dietary habits were obtained from standardized food frequency questionnaires collected at entry to the Diverticular Disease Registry (REMAD). We compared controls (C) (n = 119) with asymptomatic diverticulosis (D) (n = 344), symptomatic uncomplicated diverticular disease (SUDD) (n = 154) and previous diverticulitis (PD) (n = 83) patients, in terms of daily calories, macro and micronutrients and dietary vitamins. Daily kcal intake and lipids, both saturated and unsaturated, were significantly lower in patients with DD than C. Total protein consumption was lower in PD than D, with differing consumption of unprocessed red meat, white meat and eggs between groups. Consumption of fibre, both soluble and insoluble, was lower in patients with PD compared to patients with SUDD, D and C, whereas dietary vitamins A, C, D and E and Oxygen Radical Adsorbance Capacity index were lower in all DD groups compared to C. This observational study showed that DD patients have different dietary habits, mainly in terms of caloric, fat, fibre and vitamin intake, compared to control subjects.

Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study

Background

Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions.

Objectives

We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups.

Methods

The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year.

Results

Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery.

Limitations

The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers.

Conclusions

Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective.

Future work

For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery.

Study registration

This study is registered as reviewregistry784.

Funding

This project was funded by the National Institute for Health and Care Research (IHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Acute Diverticulitis in Young Patients: A Review of the Changing Epidemiology and Etiology

Acute diverticulitis is one of the leading gastrointestinal causes for hospitalization. The incidence of acute diverticulitis has been increasing in recent years, especially in patients under 50 years old. Historically, acute diverticulitis in younger patients was felt to represent a separate entity, being more virulent and associated with a higher rate of recurrence. Accordingly, young patients were often managed differently to older counterparts. Our understanding of the natural history of this condition has evolved, and current clinical practice guidelines suggest age should not alter management. The purpose of this review is to evaluate the changing epidemiology of acute diverticulitis, consider potential explanations for the observed increased incidence in younger patients, as well as review the natural history of acute diverticulitis in the younger population.

Variation in the rates of emergency surgery amongst emergency admissions to hospital for common acute conditions

Background

This paper assesses variation in rates of emergency surgery (ES) amongst emergency admissions to hospital in patients with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia, and intestinal obstruction.

Methods

Records of emergency admissions between 1 April 2010 and 31 December 2019 for the five conditions were extracted from Hospital Episode Statistics for 136 acute National Health Service (NHS) trusts in England. Patients who had ES were identified using Office of Population Censuses and Surveys (OPCS) procedure codes, selected by consensus of a clinical panel. The differences in ES rates according to patient characteristics, and unexplained variations across NHS trusts were estimated by multilevel logistic regression, adjusting for year of emergency admission, age, sex, ethnicity, diagnostic subcategories, index of multiple deprivation, number of co-morbidities, and frailty.

Results

The cohort sizes ranged from 107 325 (hernia) to 268 253 (appendicitis) patients, and the proportion of patients who received ES from 11.0 per cent (diverticular disease) to 92.3 per cent (appendicitis). Older patients were generally less likely to receive ES, with adjusted odds ratios (ORs) of ES for those aged 75–79 versus those aged 45–49 years: 0.34 (appendicitis), 0.49 (cholelithiasis), 0.87 (hernia), and 0.91 (intestinal obstruction). Patients with diverticular disease aged 75–79 were more likely to receive ES than those aged 45–49 (OR 1.40). Variation in ES rates across NHS trusts remained after case mix adjustment and was greatest for cholelithiasis (trust median 18 per cent, 10th to 90th centile 7–35 per cent).

Conclusion

For patients presenting as emergency hospital admissions with common acute conditions, variation in ES rates between NHS trusts remained after adjustment for demographic and clinical characteristics. Age was strongly associated with the likelihood of ES receipt for some procedures.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study

Background

The management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease.

Methods

Patients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission.

Results

In total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation.

Conclusion

Non-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.

Risk of Emergency Surgery or Death After Initial Nonoperative Management of Complicated Diverticulitis in Scotland and Switzerland

Importance

National guidelines on interval resection for prevention of recurrence after complicated diverticulitis are inconsistent. Although US and German guidelines favor interval colonic resection to prevent a perceived high risk of recurrence, UK guidelines do not.

Objectives

To investigate patient management and outcomes after an index inpatient episode of nonoperatively managed complicated diverticulitis in Switzerland and Scotland and determine whether interval resection was associated with the rate of disease-specific emergency surgery or death in either country.

Design, Setting, and Participants

This secondary analysis of anonymized complete national inpatient data sets included all patients with an inpatient episode of successfully nonoperatively managed complicated diverticulitis in Switzerland and Scotland from January 1, 2005, to December 31, 2015. The 2 countries have contrasting health care systems: Switzerland is insurance funded, while Scotland is state funded. Statistical analysis was conducted from February 1, 2018, to October 17, 2019.

Main Outcomes and Measures

The primary end point defined a priori before the analysis was adverse outcome, defined as any disease-specific emergency surgical intervention or inpatient death after the initial successful nonsurgical inpatient management of an episode of complicated diverticulitis, including complications from interval elective surgery.

Results

The study cohort comprised 13 861 inpatients in Switzerland (6967 women) and 5129 inpatients in Scotland (2804 women) with an index episode of complicated acute diverticulitis managed nonoperatively. The primary end point was observed in 698 Swiss patients (5.0%) and 255 Scottish patients (5.0%) (odds ratio, 0.98; 95% CI, 0.81-1.19). Elective interval colonic resection was undertaken in 3280 Swiss patients (23.7%; median follow-up, 53 months [interquartile range, 24-90 months]) and 231 Scottish patients (4.5%; median follow-up, 57 months [interquartile range, 27-91 months]). Death after urgent readmission for recurrent diverticulitis occurred in 104 patients (0.8%) in Switzerland and 65 patients (1.3%) in Scotland. None of the investigated confounders had a significant association with the outcome apart from comorbidity.

Conclusions and Relevance

This study found no difference in the rate of adverse outcome (emergency surgery and/or inpatient death) despite a 5-fold difference in interval resection rates.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Incidence and recurrence rate of sigmoid diverticulitis in patients requiring admission to hospital in Iceland from 1985 to 2014: nationwide population-based register study

BACKGROUND

Diverticulitis is the most common complication of diverticular disease, affecting 10-25 per cent of patients with diverticula. A retrospective, nationwide, population-based cohort study was performed to analyse the incidence and recurrence rate of sigmoid diverticulitis requiring hospital admission.

METHODS

All patients discharged from hospital in Iceland during 1985-2014 who were diagnosed with diverticular disease were included. The χ2 test was used to analyse the trend of the incidence in the period 2002-2014. The Kaplan-Meier method and the Cox model were used to analyse recurrence.

RESULTS

Of 8660 admissions for diverticular disease, 4746 were due to diverticulitis, of which 2939 were for diverticulitis diagnosed for the first time. After the first attack, surgery was used to treat 661 patients. Of 2278 patients not treated by resection, 537 had a second attack (23·6 per cent). There was a significant decrease in the incidence of diverticulitis in patients aged 40-89 years during the period from 2002 to 2014 (P = 0·033). The risk of recurrence was associated with younger age at first attack and female sex (P < 0·001).

CONCLUSION

There was a decline in the incidence of patients hospitalized with diverticulitis between 1995 and 2014, most prominent in older age groups. Different recurrence rates were reported in men and women, and in younger compared with older age groups.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Acute diverticulitis: old challenge, current trends, open questions

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

BACKGROUND

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015.

METHODS

Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed.

RESULTS

A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year).

CONCLUSIONS

From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Follow up colonoscopy may be omissible in uncomplicated left-sided acute diverticulitis diagnosed with CT- a retrospective cohort study

International guidelines recommend colonoscopy following hospitalisation for acute diverticulitis. There is a paucity of evidence supporting the efficacy of colonoscopy in this context, particularly for patients with CT-diagnosed uncomplicated left-sided diverticulitis. This study aims to investigate the frequency that colorectal cancer (CRC) and advanced adenomas (AA) are identified during follow-up colonoscopy after hospitalisation with CT-proven left-sided diverticulitis for the first time in a UK population. In this single-centre retrospective-cohort study all patients presenting with CT-diagnosed uncomplicated left-sided diverticulitis between 2014 and 2017 were identified. The incidence of histologically confirmed CRC and AA identified at follow-up colonoscopy 4–6 weeks following discharge was assessed. 204 patients with CT proven uncomplicated left-sided diverticulitis underwent follow-up colonoscopy. 72% were female and the median age was 63 years. There were no major complications. 22% of patients were found to have incidental hyperplastic polyps or adenomas with low-grade dysplasia. No CRC or AA were found. Routine colonoscopy following acute diverticulitis in this cohort did not identify a single CRC or AA and could arguably have been omitted. This would significantly reduce cost and pressure on endoscopy departments, in addition to the pain and discomfort that is commonly associated with colonoscopy.

Surgical treatment of acute complicated diverticulitis in the elderly

Although the true prevalence is unknown, colonic diverticulosis is one of the most common disease of the digestive tract in Western countries. Based on administrative data of hospitalized patients, the incidence of diverticulitis has been increasing in last decades. In general, elderly patients undergo less frequently an elective colonic resection; but a substantial part of emergency surgeries is performed in elderly patients. In these older patients the choice of any clinical and surgical option is to be correlated not only to the severity of diverticulitis, but also to general status and the co-existing comorbidities. In this regard, it is mandatory that all patients undergo a multidimensional, comprehensive geriatric assessment to correctly identify those who are fit, vulnerable or frail. The analysis of data currently available highlights three relevant elements: type and severity of peritoneal contamination, hemodynamic conditions (stable or unstable), and concomitant comorbidities (fit or frail status). There is no single ideal surgical treatment that can be considered as gold standard for all clinical presentations; the final clinical decision-making should always be based on patient's general health status, severity of peritonitis and of sepsis. In a septic elderly patient who is hemodynamically unstable, treatment should be as prompt as possible independent of the Hinchey's stage, and could include either a Mickulicz stoma or a DCS strategy. In an elderly patient who is fit and hemodynamically stable, the surgical options are similar to those in a younger patient. If a patient is frail but hemodynamically stable, he should be treated with a Hartmann's procedures.

Diverticular disease epidemiology: acute hospitalisations are growing fastest in young men

BACKGROUND

Older age has long been linked to risk of diverticulitis, but the epidemiology is seldom described for a national population. The aim of this study was to investigate age- and gender differences in incidence, temporal trends, lifetime risk and prevalence related to acute diverticulitis hospitalisations in New Zealand.

METHODS

Records of all hospitalisations with diverticulitis the primary diagnosis were obtained from the Ministry of Health for the period 2000-2015. The first acute diverticulitis admission recorded for an individual was taken as an incident event; all others were classified as recurrent. Trends in age- and sex-specific and age-standardised incidence rates are described, and lifetime risk and prevalence estimated.

RESULTS

Over the 16 years from 2000 to 2015, 37,234 acute hospitalisations for diverticulitis were recorded in 28,329 people aged 30 + years (median = 66 years). Rates of incident hospitalisations rose with age, from 5/10,000 person-years at age 50-54 years to 19/10,000py by age 80-84 years. Rates for women were lower than men before age 55 years, but higher thereafter. Age-standardised rates rose 0.2/10,000py annually, but approximately doubled among men aged < 50 years. Lifetime risk was estimated at over 5%, with the prevalence pool rising to over 1.5% of the population aged 30+ in 2030.

CONCLUSIONS

Rapid increases in diverticulitis admissions among young men since 2000 correspond with increases reported elsewhere but remain unexplained; notably young women follow similar trends 5-10 years later. Increasing incidence, combined with population ageing, adds urgency to explain diverticular formation, to understand factors that trigger or provoke their inflammation/infection, and to clarify treatment and (self-)management pathways.

Socio-economic disparity in risk of undergoing emergency laparotomy and postoperative mortality

Aims: Socio-economic disparities in health and access to care are well documented, but socio-economic disparities in surgical care and outcomes have received less attention. The aim of the study was to determine if there are socio-economic disparities in the risk of undergoing emergency laparotomy and postoperative mortality in a universal health-care system with free and equal access to care. Methods: This was a nationwide case-control study including patients undergoing non-malignant emergency laparotomy involving resection, ostomy or open drainage between 2003 and 2014 and population references matched 1:1 on age and sex. Socio-economic disparities in one-year postoperative mortality were explored through a cohort study including all patients. Exposure measures were register-based household disposable income, educational level and employment status. Analyses were adjusted by age, sex, country of origin, marital status and co-morbidity. Results: A total of 11,962 cases and 11,962 population references were included. The highest odds ratios (OR) for undergoing surgery were found among those with the lowest income (OR=1.51; 95% confidence interval (CI) 1.39–1.63), those with elementary school education (OR=1.33; 95% CI 1.22–1.46) and those on early-retirement pension (OR=3.49; 95% CI 3.07–3.98). One-year postoperative mortality was highest among those with lowest income (hazard ratio (HR)=1.51; 95% CI 1.35–1.69), those with elementary school education (HR=1.39; 95% CI 1.22–1.59) and those on early-retirement pension (HR=2.12; 95% CI 1.73–2.61). Conclusions: Socio-economic disparities in health exist in relation to non-malignant emergency laparotomies and still exist after adjustment for confounders, including co-morbidity, indicating that mechanisms other than differences in disease burden are involved. There is a substantial need for exploration of mechanisms and preventive measures.

Incidence and lifetime risk of hospitalization and surgery for diverticular disease

BACKGROUND

Studies on incidence rates of first-time colonic diverticular disease are few, and population-based estimates of lifetime risk are lacking. In this observational study, the incidence, admission rates and lifetime risks of hospitalization and surgery for diverticular disease were investigated.

METHODS

Considering the entire Swedish population as an open cohort, incidence and admission rates, and lifetime risk estimates (considering death as a competing risk) of hospitalization and surgery for diverticular disease were calculated using data from cross-linked national registers and population statistics from 1987 to 2010.

RESULTS

In total, there were 144 107 hospital admissions for diverticular disease in 95 049 individual patients. Of these, 17 599 were admissions with bowel resection or stoma formation in 16 824 patients. The total number of person-years in the population during the study period was 213 949 897. Age-standardized incidence rates were 47·4 (95 per cent c.i. 47·1 to 47·7) for first-time hospitalization with diverticular disease and 8·4 (8·2 to 8·5) per 100 000 person-years for diverticular disease surgery. The corresponding admission rates (including readmissions) were 70·8 (70·4 to 71·2) and 8·7 (8·6 to 8·9) per 100 000 person-years. Following an increase in 1990-1994, rates stabilized. Based on incidence and mortality rates from 2000 to 2010, the estimated remaining lifetime risk of hospitalization from 30 years of age was 3·1 per cent in men and 5·0 per cent in women. The corresponding risk of surgery was 0·5 per cent in men and 0·8 per cent in women.

CONCLUSION

Diverticular disease is a common reason for hospital admission, particularly in women, but rates are stable and the lifetime risk of surgery is low.

Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015

BACKGROUND

Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015.

METHODS

Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed.

RESULTS

174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)].

CONCLUSIONS

In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.

Emergency admissions for complicated colonic diverticulitis are increasing: a nationwide register-based cohort study

BACKGROUND

Acute colonic diverticulitis is common in the Western world representing a growing burden on health care. We aimed to report the factual epidemiological and demographic characteristics in patients with acute diverticulitis in a large nationwide population.

METHOD

We conducted a population-based cohort study from 2000 to 2012 on the complete Danish population, which included all patients with acute colonic diverticulitis. Data were composed through two national longitudinal registries. The study main outcomes were demographic development regarding hospital admission, age, gender, geographical residency, and seasonal information.

RESULTS

A total of 101,963 acute hospital contacts were identified from 2000 to 2012, of these 44,160 were due to acute diverticulitis. From 2000 to 2012, overall admission rates for complicated diverticulitis increased significantly with 42.7%. There was a small increase in hospital admissions due to acute diverticulitis, and uncomplicated diverticulitis accounted for 83-88% of all admissions. No significant development was seen in cases of uncomplicated diverticulitis. The majority of patients were older than 50 years (85%) and 60% were women. The male gender dominated in patients younger than 50 years (58%), whereas women dominated above 50 years (63%). Mean age and dominating age group decreased significantly from 2000 to 2012 for both genders. A significantly larger proportion of male patients had complicated diverticulitis than uncomplicated diverticulitis. Most admissions were seen during autumn.

CONCLUSION

We found that acute colonic diverticulitis has been progressing over the last decade with more severe cases of disease. Our findings underline the need for further research to identify the relevant risk factors and causal circumstances.

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.

International Variation in Emergency Operation Rates for Acute Diverticulitis: Insights into Healthcare Value

BACKGROUND

International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia.

METHODS

Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system.

RESULTS

There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p < 0.001) and England (OR 1.49, p < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk.

CONCLUSION

Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.

Foreign bodies in sigmoid colon diverticulosis

This review addresses the management of sigmoid colon diverticular disease associated with foreign bodies. In addition, two novel cases are presented. One case describes the management of diverticular bleeding secondary to a chicken bone and the other case reports retrieval of a retained EndoRings™ Device. The review identified 40 relevant publications including 50 subjects. Foreign bodies within sigmoid diverticular disease may be associated with inflammation, perforation, abscess and fistula. In current practice, diagnosis is often achieved with CT scan. Patients with colonic perforation or fistula generally require colonic resection. Patients with inflammation may merit conservative management, including colonoscopic foreign body retrieval. Chicken bones, tooth picks, and biliary stents have been reported in patients with inflammation, perforation and fistula, whereas all published patients with fish bone related diverticulosis complications experienced inflammation. Treatment might be best guided by the consequences of the foreign body rather than the nature of the underlying retained object. Diverticular bleeding secondary to a chicken bone was diagnosed at CT angiography and treated with colonoscopic snare retrieval of the bone and clipping of the bleeding diverticulum. The EndoRings™ Device was retrieved with a colonoscopic balloon.

Impact of diverticular inflammation and complication assessment classification on the burden of medical therapies in preventing diverticular disease complications in Italy

BACKGROUND

Several treatments are currently advised to manage diverticular disease (DD) patients, but their impact on the burden of the disease is unknown. Our aim was to assess the economic analysis of using the recent Diverticular Inflammation and Complication Assessment (DICA) endoscopic classification on the burden of medical therapies prescribed in preventing DD complications occurrence in Italy.

METHODS

We assessed retrospectively the cost/year of treatments in estimated DICA 1, DICA 2 and DICA 3 population. Analysis of diverticulosis prevalence was estimated according to data population provided by Italian Institute of Statistics (ISTAT). Cost of treatments calculated according to data on drugs' consumption collected during the DICA study.

RESULTS

We estimated that >8 million of Italian people >60 years may have diverticulosis, and that about 75% of diverticular population are on DICA 1, about 30% on DICA 2, and about 13% on DICA 3. We estimated that >387 million of euros could be spent in DICA 1 population, >203 million of euros in DICA 2 population, and >88 million of euros in DICA 3 population. Since medical treatments did not show any significant advantage when treating DICA 1 and DICA 3 people in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence, we can estimated that >475 million of euros could be spent in Italy without any significant benefit in preventing DD complications occurrence.

CONCLUSIONS

DICA endoscopic classification may have a significant impact on the burden of DD in Italy, because it helps to select DD people who effectively need treatments in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence.

The Economic Burden of Diverticular Disease

Diverticular disease (DD) of the colon represents a common clinical condition affecting from one-fourth to one-third of the population in developed countries. Several epidemiological studies have clearly shown that in the last decades the rates of clinic visits and hospital admissions for DD and its complications are progressively increased. In addition, complications of DD are associated to a high mortality rate that continues unabated despite advances in surgery and intensive care. As consequence, the burden on health care resources has significantly increased over time, leading DD among the main causes of health spending for gastrointestinal diseases. In this review the most important data regarding health care resources utilization and costs for DD are analyzed and some proposals for reducing the burden on health care systems are hypothesized.

Operative intervention rates for acute diverticulitis: a multicentre state-wide study

BACKGROUND

Acute colonic diverticulitis is placing an increasing strain on our health care resources. Measurement of the problem is difficult at a regional level, yet essential to improve and optimize treatment of this condition. Therefore, we aimed to use Australian state-level administrative data to determine the current practice and outcomes in major metropolitan hospitals.

METHODS

Coding algorithms designed to increase the yield and accuracy of administrative data were used to find emergency admissions from the Victorian Admitted Episodes Dataset. Eight tertiary referral centres with specialist colorectal services from 2009 to 2013 were studied. Key metrics including the operative intervention rate were measured.

RESULTS

There were 2829 emergency admissions for acute diverticulitis across 4 years in eight hospitals, with 724 being complicated. The emergency operative intervention rate was 10.4%, with a third of admissions for complicated diverticulitis having an operation. Hartmann's procedure was the most commonly performed emergency operation, accounting for 72% of resections. Patient characteristics were consistent across the hospitals, including a median length of stay of 3 and 6 days for uncomplicated and complicated diverticulitis, respectively.

CONCLUSION

Hartmann's procedure is currently the most common emergency operation for acute complicated diverticulitis in Victorian metropolitan hospitals. Our practice and outcomes can be measured meaningfully using administrative data.