Determinants of treatment and outcomes of diverticular abscesses

Safety and efficacy of EUS-guided pelvic abscess drainage with lumen-apposing metal stents for complicated acute diverticulitis

BACKGROUND AND AIMS

EUS-guided pelvic abscess drainage (EUS-PAD) with a lumen-apposing metal stent (LAMS) is an alternative approach for postsurgical and inflammatory pelvic collections. This study assessed the safety and efficacy of EUS-PAD with an LAMS in a large population of complicated acute diverticulitis (AD).

METHODS

Data were retrieved on consecutive patients who underwent EUS drainage attempts for complicated AD from 2019 to 2023 in 3 referral centers. All cases have been considered suitable for EUS-PAD after multidisciplinary discussion. Continuous variables are expressed as median (IQR).

RESULTS

Data on 66 patients were retrieved; in 13 cases, EUS-PAD was not indicated because no or small abscess was found. Fifty-three patients (29 female subjects; age, 74 [62-83] years) were finally included. Forty (75.5%) patients had a pelvic abscess, and 13 (24.5%) had a para-colonic abscess, with a median size of 50 (40-60) mm. Transrectal and transcolonic EUS-PAD procedures were performed in 34 (64.2%) and 19 (35.8%) cases, respectively. Technical and clinical success rates were 92.5% and 88.7%; incidence of adverse events was 3.8% (1 bleeding, 1 late migration). LAMSs were removed after 19 (14-28) days. Median follow-up was 12 (8-12) months. Four (7.5%) patients underwent an urgent Hartmann sigmoidectomy, and 12 (22.6%) patients required elective surgery; 2 (3.8%) patients presented with recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed.

CONCLUSIONS

EUS-PAD could be considered a safe and effective rescue strategy in case of a failed or contraindicated percutaneous approach for the management of complicated AD to reduce the need for urgent surgery. Comparative data are necessary to confirm these observations.

Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease

Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.

Effectiveness of Treatment with Antibiotics Alone in Patients with Acute Diverticulitis and Pelvic Abscesses

Introduction: The available evidence regarding the treatment of acute diverticulitis (AD) with pelvic abscess using antibiotics alone is very limited. The objective of this study was to determine whether the short- and long-term outcomes of AD with pelvic abscesses treated exclusively with antibiotics are comparable to those of pericolic abscesses. Methods: A retrospective study was conducted on patients diagnosed with AD and either pelvic or pericolic abscesses, as confirmed by computed tomography, who were treated solely with antibiotic therapy between 2011 and 2021. Cases involving percutaneous drainage as part of conservative treatment were excluded. Results: Fifty-eight patients met the inclusion criteria, comprising 12 with pelvic abscesses and 46 with pericolic abscesses. Both groups exhibited similar baseline characteristics and radiological findings, except for a more frequent presence of free fluid in pelvic abscesses. The success rate of antibiotic therapy was 91.7% for pelvic abscess cases and 96.7% for pericolic cases (p = 0.508). No significant differences were observed in recurrence or elective surgery. In the subgroup of abscesses with a diameter ≥4 cm, the evolution was similar in both locations (treatment success rate of 87.5% in pelvic and 94.4% in pericolic; p = 0.529), although recurrence was slightly higher for pericolic abscesses (38.4% vs. 14.3%; p = 0.362). Conclusions: Antibiotic therapy alone proves to be effective and safe for pelvic abscesses, demonstrating a course similar to pericolic abscesses, even in the case of large abscesses. Although the analyzed patient cohort is small, this study provides additional evidence that percutaneous drainage is not always essential for treating this complication.

Clinical relevance of the 3-cm threshold in sigmoid diverticulitis with abscess: consensus or quandary?

PURPOSE

Diverticular abscess is a common manifestation of acute complicated diverticulitis. We aimed to analyze the clinical course of patients with diverticular abscess initially treated conservatively.

METHODS

All patients with diverticular abscess undergoing elective or urgent/emergency surgery from October 2004 to October 2022 were identified from our institutional database. Depending on the abscess size, patients were divided into group A (≤ 3 cm) and group B (> 3 cm). Conservative treatment failure was defined as clinical deterioration, persistent or recurrent abscess, or urgent/emergency surgery. Baseline characteristics and short-term perioperative outcomes were recorded and compared between both groups. Uni- and multivariate analyses were conducted to identify determinants of conservative treatment failure and overall ostomy formation.

RESULTS

A total of 105 patients were enrolled into group A (n = 73) and group B (n = 32). Uni- and multivariate analyses revealed abscess size as the only significant factor of conservative therapy failure [OR 9.904; p < 0.0001], while overall ostomy formation was significantly affected by an increased body mass index (BMI) [OR 1.366; p = 0.026]. There were no significant differences in perioperative outcome with the exception of a longer total hospital stay in patients managed with abscess drainage compared to antibiotics alone prior surgery in group B (p = 0.045).

CONCLUSION

Abscess diameter > 3 cm is not just an arbitrary chosen cut-off value for drainage placement but has a prognostic impact on medical treatment failure in patients with complicated acute diverticulitis. In this subgroup, the choice between primary drainage and antibiotics does not appear to influence outcome at the cost of prolonged hospital stay after drainage insertion.

Results of surgical treatment of patients with acute destructive diverticulitis of the colon using minimally invasive technologies

Among the diseases of the colon, diverticular disease occupies one of the leading positions, the frequency of which is currently 1.2 cases per 1000 people. Complications in this condition develop in 5% of cases and account for 3-5% of all patients with acute abdominal diseases. Surgical intervention is required in 15% to 30% of such patients. The mortality rate after surgical treatment of acute complications of the diverticular disease remains high, ranging from 7% to 25%. The purpose of our study was to compare the outcomes in the treatment of patients with acute destructive diverticulitis of the colon using traditional surgical treatment versus minimally invasive technologies. In the study, 114 patients diagnosed with acute destructive diverticulitis were examined. Group I consisted of 56 patients who underwent initial surgical interventions employing minimally invasive methods like laparoscopy, laparoscopic-assisted techniques, or percutaneous drainage guided by ultrasound. Group II comprised 58 patients who underwent the first surgical intervention through laparotomy access. The data of our study show that the overall proportion of patients with complications was higher in Group II – 20 (34.5%) compared to 6 (10.1%) in Group I (p=0.005). The application of diverse surgical methods did not notably impact the mortality rate, with 6 (10.3%) fatalities in Group II compared to 2 (3.6%) in Group I (p=0.2). Stoma creation was more frequent in Group II, in 40 (67%) patients, whereas in Group I, the occurrence of stomas was lower, in 15 (25.9%) cases. The average period to stoma closure was 5 months in Group II and 2 months in Group I. There was observed a decrease in the time of urgent surgery from 143±13.5 minutes in Group II to 65.7±15.2 minutes in Group I (p<0.01) and the duration of the first hospitalization from 14.2±1.8 days to 5.6±0.7 days, accordingly (p<0.01). When dealing with primary anastomosis or severe peritonitis, utilizing a laparoscope for dynamic laparoscopy allows for real-time monitoring of the abdominal cavity and early identification of complications, eliminating the need for scheduled laparostomy. The research data demonstrate that, while not affecting mortality, minimally invasive methods have several significant advantages, including a reduction in the number of complications, a decrease in the proportion of patients with stomas, a reduction in the time to reconstructive surgery, and a decrease in the duration of urgent surgery and the length of hospitalization.

Surgical and non-operative treatment of acute complicated diverticulitis in a COVID hospital

Surgical treatment of acute abdomen during the SARS-CoV-2 pandemic was accompanied by an extremely high mortality rate, however, only a few studies have presented the results of acute inflammatory complications of diverticular disease (AICDD).AIM: analysis of treatment of AICDD in a COVID-19 hospital.PATIENTS AND METHODS: the retrospective study included 78 patients with acute diverticulitis (AD) from a COVID hospital, confirmed by CT or intraoperative revision. Assessment of COVID pneumonia, comorbidities, organ dysfunction, CT findings, peritonitis, treatment methods, and in-hospital mortality among patients was performed.RESULTS: organ dysfunction of ≥ 1 point on the qSOFA scale was detected in 59.0% of the patients. According to CT data, abdominal distant gas was detected in 48 (61.5%) patients, and pericolic gas in 14 (17.9%) patients. Segmental colon resection was performed in 60 (76.9%) patients, laparoscopic lavage (LL) of the abdominal cavity — in 3, non-operative treatment (NOT) with drainage of fluid collections — in 6, and only NOT in 10 patients. Most patients with distant or pericolic gas were operated on within an average time of 1 [0; 3.5] hours after admission. Diffuse peritonitis was detected during surgery in 45 (75%) of them. After resection, organ dysfunction of ≥ 2 points on the SOFA scale developed or progressed in 52 (86.7%) patients. The overall mortality rate was 48.7%, and the postoperative mortality was 63.3%. All patients (n = 38) died after segmental colon resection. Successful NOT was achieved in 4 patients with pericolic gas and 3 patients with distant gas.CONCLUSION: surgery for AICDD in patients with COVID-19 is associated with extremely high mortality, therefore, in the absence of obvious signs of diffuse peritonitis, initial non-operative treatment may be life-saving.

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study

BACKGROUND

This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses.

METHODS

This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed.

RESULTS

Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23).

CONCLUSIONS

Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

Emergency medicine updates: Acute diverticulitis

INTRODUCTION

Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician.

DISCUSSION

Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group

BACKGROUND

To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery.

METHODS

This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed.

RESULTS

Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85).

CONCLUSION

Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends

Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.

Efficacy of endoscopic ultrasound-guided abscess drainage for non-pancreatic abscesses: A retrospective study

BACKGROUND AND AIM

Percutaneous drainage of intra-abdominal abscesses is often uncomfortable for the patient and may result in prolonged hospital stays. Recent studies have shown that endoscopic ultrasound-guided abscess drainage (EUS-AD) could effectively treat various abscesses and fluid collections. However, no indications or procedures have been established for EUS-AD treatments, and studies on its usefulness and safety are insufficient. The present study aimed to evaluate the efficacy and safety of EUS-AD for treating non-pancreatic abscesses.

METHODS

This retrospective study included 20 patients, aged ≥20 years, who underwent EUS-AD for an abscess or fluid accumulation in the abdomen or mediastinum, but not the pancreas. Patients were treated at the Kawasaki University General Medical Center between March 2013 and June 2021. All EUS-AD procedures were performed prior to a percutaneous drainage or surgical drainage.

RESULTS

Among the 20 patients who underwent an EUS-AD for abscess, 8 (40%) had liver abscesses, 6 (30%) had intraperitoneal abscesses, 3 had (15%) splenic abscesses, 1 (5%) had a mediastinal abscess, 1 (5%) had an iliopsoas abscess (n = 1, 5%), and 1 (5%) had an abdominal wall abscess. The technical success rate was 95% (n = 19/20). We inserted nasobiliary catheters in 4/20 patients (20%). The clinical success rate was 90% (n = 18/20). Two clinical failures required reintervention, and both were treated with percutaneous drainage. Adverse events were observed in 2/20 patients (10%). One patient experienced fever after the procedure, and the other experienced localized peritonitis.

CONCLUSION

EUS-AD was effective and safe for abscess removal, particularly when approached from the upper gastrointestinal tract.

Short- and long-term outcomes in the nonoperative treatment of diverticular abscesses

Introduction

Recommendations for surgery of diverticular abscesses continue to evolve. This study aimed to examine the short- and long-term results of nonoperative management of diverticular abscesses while analyzing granular data to assess for predictive factors for successful treatment.

Materials and methods

We analyzed patients admitted with diverticular abscesses at Penn Highlands Mon Valley Hospital from 2010 to 2020 who received initial planned nonoperative management. Short-term failure was defined as requiring surgery within 60 days of diagnosis, whereas long-term failure was defined as requiring surgery beyond 60 days. Successful treatment was defined as treatment that did not require surgery.

Results

In total, 857 patient charts were individually analyzed. Sixty-three patients met the inclusion criteria. The median follow-up period was 48 months. Nineteen (30.2%) patients experienced short-term failure of nonoperative management, whereas 6 (9.5%) patients experienced long-term failure. Surgery was successfully avoided in the remaining 41 (60.3%) patients. Abscess size was significantly associated with success rate (< 3 cm, 85.7%; 3-5 cm, 42.3%; > 5 cm, 33.3%; p = 0.001). When corrected for the abscess size, percutaneous drainage did not affect the requirement for eventual surgery.

Conclusions

Nonoperative management is a reasonable option for diverticular abscesses and is particularly successful in patients with abscesses < 3 cm in diameter. Although sometimes performed in conjunction with nonoperative management, percutaneous drainage does not decrease the requirement for eventual surgery. Elective surgery should be considered for patients with larger abscesses. Future prospective studies may further clarify the role of the nonoperative management of diverticular abscesses.

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager^® and ProduXion Manager^® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole.

Stoma reversal after Hartmann's procedure for acute diverticulitis

BACKGROUND

Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out of fear of high permanent stoma rate. The aim of this study was to investigate the rate of stoma reversal, reasons behind nonreversal, and safety of reversal surgery.

METHODS

This was a single-center retrospective study of patients undergoing urgent Hartmann's procedure due to acute diverticulitis between the years 2006 and 2017 with follow-up until March 2021.

RESULTS

A total of 3,319 episodes of diverticulitis in 2,932 patients were screened. The Hartmann's procedure was performed on 218 patients, of whom 157 (72%) had peritonitis (48 (22%) with organ dysfunction). At 2-years, 76 (34.9%) patients had died with stoma, 42 (19.3%) were alive with stoma, and 100 (45.9%) had undergone stoma reversal. The survival of patients with and without reversal were 100% and 42.7% at 1-year, 96.0% and 35.0% at 2-years and 88.9% and 20.7% at 5-years, respectively. The risk factors for nonreversal were old age, a need for outside assistance, low HElsinki Staging for Acute Diverticulitis stage, and higher C-reactive protein level upon hospital admission. The most common reasons for nonreversal in surviving patients were patient not willing to have the operation 18 (41%) and dementia 10 (23%). Twelve (12%) patients had a major complication after reversal (Clavien-Dindo IIIb-IV) and 90-day mortality after reversal was 0%.

CONCLUSION

After the Hartmann's procedure for acute diverticulitis, one-third died, half underwent stoma reversal, and one-fifth did not undergo stoma reversal within 2 years. Patients who survive with stoma are either not willing to have reversal or have severe comorbidities excluding elective surgery. The Hartmann's procedure remains a viable option for high-risk patients with perforated acute diverticulitis.

Diverticular disease: a clinical review

Diverticular disease is an umbrella term encompassing symptomatic diverticulosis, uncomplicated and complicated diverticulitis. The presence of diverticula increases with age, affecting up to 70% of the population by 80 years of age. It is associated with a significant economic burden in terms of healthcare costs, hospitalisation, and resource use. Although mortality from non-complicated diverticulosis is extremely rare, morbidity and mortality risk increase ten-fold with complications such as perforation or fistula. This article will examine diverticular disease, its pathogenesis, symptoms and complications. Additionally, the surgical and non-surgical treatment options will be discussed, including the role of antibiotics.

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review

BACKGROUND

Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.

PURPOSE

To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.

STUDY SELECTION

Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.

DATA EXTRACTION

6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.

DATA SYNTHESIS

Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).

LIMITATIONS

The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.

CONCLUSION

Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.

METHODS

The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.

TARGET AUDIENCE AND PATIENT POPULATION

The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis.

RECOMMENDATION 1

ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence).

RECOMMENDATION 2

ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence).

RECOMMENDATION 3

ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence).

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Intraperitoneal abscess from perforated diverticulitis with fistualization to extraperitoneal abscess into the scrotum: a case report

Background

Scrotal abscesses are common skin abscesses seen in the general population; however, intraperitoneal abscesses tracking into the scrotum are rare. Intraperitoneal and retroperitoneal abscesses contiguous with the scrotum have been reported in the literature in specific populations. Wound cultures can aid in differentiating the source of the infections. Recurrent abscesses have been observed in high-risk populations, such as those with malignancy or who are immunocompromised.

Case presentation

We present a 71-year-old male with pericolonic abscess following perforated diverticulitis. The abscess was drained with interventional radiology and was complicated by an extraperitoneal abscess that tracked to the scrotum. Incision and drainage of the extraperitoneal abscess and the scrotal abscess were required with intravenous antibiotic therapy. The abscess tracking into the scrotum is reported without evidence of patent processus vaginalis.

Conclusion

We conclude that an intraperitoneal abscess can track to the scrotum through extraperitoneal fascial planes in the absence of a patent processus vaginalis. We show that extraperitoneal abscess spread to the scrotum is possible, with wound cultures helping to differentiate the source of the infection. High-risk patients with recurrent abscesses can also be susceptible to contiguous spread.

Recurrent, Complicated Diverticulitis With Atypical Features

Diverticular disease is a common condition responsible for significant costs to the healthcare system in the Western world. It ranges from asymptomatic diverticulosis to complicated diverticulitis. Here, we present a unique case of recurrent, complicated diverticulitis in a 62-year-old Caucasian male. Within a span of one year, he was hospitalized six times with diverticulitis before undergoing elective sigmoid colon resection. Imaging showed diverticulitis of distal descending and proximal sigmoid colon with sealed perforation, recurrent abscesses, and formation of colocutaneous fistulas. During each hospitalization, the patient was advised to follow up with general surgery and/or outpatient gastroenterology but chose not to do so. Eventually, he required an elective sigmoid colectomy with a takedown of the colocutaneous fistulas. In this case report, we discuss the atypical features and criteria for prophylactic colon resection in diverticulitis to highlight the importance of outpatient follow-up with general surgery and gastroenterology.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series

AIM

Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).

METHODS

All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.

RESULTS

Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).

CONCLUSIONS

Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

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.

Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis

The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective.

Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial

BACKGROUND

Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial.

METHODS

This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively.

RESULTS

Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840).

CONCLUSION

Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

Outcomes after CT guided drainage of diverticular abscesses and predictive factors for fistulous communication to the colon

BACKGROUND

The purpose of the study is to analyze patient outcomes following CT guided drainage of colonic diverticular abscesses and identify the factors associated with development of fistulous communication to the drain.

METHODS

All patients undergoing CT guided abscess drainage, from 2009 to 2017, were included in this single institutional study. Clinical and demographic variables associated with development of colonic fistula were investigated.

RESULTS

One-hundred-and-five patients (55% female), mean abscess size and BMI of 6.3 cm and 30.28 kg/m², respectively, underwent CT guided abscess drainage. Patients with fistula had longer operative times (p = 0.03). On multivariable analysis, females (p = 0.02) and higher BMI (p = 0.01) were protective against, while increasing size (p = 0.01) was predictive of developing fistulous communication to the drain.

CONCLUSION

More than half of patients developed colonic fistula after CT guided drainage. Male sex, lower BMI and increasing abscess size were predictive of developing colonic fistula.

Non-operative management of small post-appendicectomy intra-abdominal abscess is safe and effective

BACKGROUND

Intra-abdominal abscess (IAA) post-appendicectomy occurs in 1.4-4.4% of cases. Non-operative management of small (<4 cm) post-appendicectomy IAA in children is well established, but minimal evidence exists in adults. Percutaneous catheter drainage is considered standard treatment for IAA, yet outcome data for post-appendicectomy IAA are sparse. The aims of this study were to assess the effectiveness of non-operative management of small (<4 cm diameter) IAA and the outcomes of percutaneous drainage for larger (>4 cm) IAA post-appendicectomy.

METHODS

A retrospective case note review of a series of patients with a post-appendicectomy IAA between 2006 and 2017 was conducted. IAAs were treated selectively; small (<4 cm) IAAs were managed non-operatively and larger IAAs were managed with percutaneous drainage .

RESULTS

A total of 4901 patients had an appendicectomy. Forty-two (0.9%) developed a post-operative IAA. Sixteen (38%) had a percutaneous drainage and 26 (62%) had non-operative management. The percutaneous drainage group had a higher proportion of complicated appendicitis (75%) compared to the non-operative group (42%, P = 0.04). The percutaneous drainage group had a significantly higher leucocytosis (P = 0.01) and C-reactive protein (P = 0.02). All patients managed non-operatively resolved without the need for invasive procedures. In the percutaneous drainage group, six had aspiration alone, nine had a percutaneous drain and one was abandoned. Three required repeat percutaneous drainage and four (25%) required operative drainage. Seven patients (34%) of the percutaneous drainage group had grade II or III complications.

CONCLUSION

This case series study provides support that small (<4 cm) IAA post-appendicectomy can be safely and effectively managed non-operatively.