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Hawkins AT, Penson DF, Geiger TM, Bonnet KR, Mutch MG, Maguire LH, Schlundt DG, Rothman RL. The Patient Perspective on Colectomy for Recurrent Diverticulitis: A Qualitative Study. Ann Surg 2024; 279:818-824. [PMID: 38318711 PMCID: PMC10997445 DOI: 10.1097/sla.0000000000006225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Understand the patient's decision-making process regarding colectomy for recurrent diverticulitis. BACKGROUND The decision to pursue elective colectomy for recurrent diverticulitis is highly preference-sensitive. Little is known about the patient's perspective in this decision-making process. METHODS We performed a qualitative study utilizing focus groups of patients with recurrent diverticulitis at 3 centers across the United States. Using an iterative inductive/deductive approach, we developed a conceptual framework to capture the major themes identified in the coded data. RESULTS From March 2019 to July 2020, 39 patients were enrolled across 3 sites and participated in 6 focus groups. After coding the transcripts using a hierarchical coding system, a conceptual framework was developed. Major themes identified included participants' beliefs about surgery, such as normative beliefs (eg, subjective, value placed on surgery), control beliefs (eg, self-efficacy, stage of change), and anticipated outcomes (eg, expectations, anticipated regret); the role of behavioral management strategies (eg, fiber, eliminate bad habits); emotional experiences (eg, depression, embarrassment); current symptoms (eg, severity, timing); and quality of life (eg, cognitive load, psychosocial factors). Three sets of moderating factors influencing patient choice were identified: clinical history (eg, source of diagnosis, multiple surgeries), clinical protocols (eg, pre-op and post-op education), and provider-specific factors (eg, specialty, choice of surgeon). CONCLUSIONS Patients view the decision to undergo colectomy through 3 major themes: their beliefs about surgery, their psychosocial context, and moderating factors that influence participant choice to undergo surgery. This knowledge is essential both for clinicians counseling patients who are considering colectomy and for researchers studying the process to optimize care for recurrent diverticulitis.
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Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Timothy M Geiger
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lilias H Maguire
- Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Russell L Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
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Stovall SL, Johnson MP, Evans ET, Kaplan JA, Law JK, Moonka R, Bahnson HT, Simianu VV. Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State. Am Surg 2023; 89:5720-5728. [PMID: 37144833 DOI: 10.1177/00031348231174002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions. METHODS A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients. RESULTS During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization). DISCUSSION Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.
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Affiliation(s)
- Stephanie L Stovall
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Meredith P Johnson
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ethan T Evans
- Diabetes Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Jennifer A Kaplan
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Joanna K Law
- Department of Gastroenterology, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Ravi Moonka
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Henry T Bahnson
- Clinical Research Program, Benaroya Research Institute, Seattle, WA, USA
| | - Vlad V Simianu
- Department of General, Thoracic, and Vascular Surgery, Virginia Mason Franciscan Health, Seattle, WA, USA
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Tong JKC, Mascuilli T, Wirtalla C, Aarons CB, Saur NM, Mahmoud NN, Kelz RR. Exploring ethnic differences in post-discharge patterns of surgical care for older adults admitted with diverticulitis. Colorectal Dis 2023; 25:1006-1013. [PMID: 36655392 PMCID: PMC10257996 DOI: 10.1111/codi.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
AIM We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort. METHODS We identified nationwide Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns. RESULTS Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001). CONCLUSION We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.
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Affiliation(s)
- Jason K C Tong
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- National Clinicians Scholars Veterans Affairs Fellow, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tory Mascuilli
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cary B Aarons
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole M Saur
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Najjia N Mahmoud
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Harold KM, MacCuaig WM, Holter-Charkabarty J, Williams K, Hill K, Arreola AX, Sekhri M, Carter S, Gomez-Gutierrez J, Salem G, Mishra G, McNally LR. Advances in Imaging of Inflammation, Fibrosis, and Cancer in the Gastrointestinal Tract. Int J Mol Sci 2022; 23:16109. [PMID: 36555749 PMCID: PMC9781634 DOI: 10.3390/ijms232416109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Gastrointestinal disease is prevalent and broad, manifesting itself in a variety of ways, including inflammation, fibrosis, infection, and cancer. However, historically, diagnostic technologies have exhibited limitations, especially with regard to diagnostic uncertainty. Despite development of newly emerging technologies such as optoacoustic imaging, many recent advancements have focused on improving upon pre-existing modalities such as ultrasound, computed tomography, magnetic resonance imaging, and endoscopy. These advancements include utilization of machine learning models, biomarkers, new technological applications such as diffusion weighted imaging, and new techniques such as transrectal ultrasound. This review discusses assessment of disease processes using imaging strategies for the detection and monitoring of inflammation, fibrosis, and cancer in the context of gastrointestinal disease. Specifically, we include ulcerative colitis, Crohn's disease, diverticulitis, celiac disease, graft vs. host disease, intestinal fibrosis, colorectal stricture, gastric cancer, and colorectal cancer. We address some of the most recent and promising advancements for improvement of gastrointestinal imaging, including unique discussions of such advancements with regard to imaging of fibrosis and differentiation between similar disease processes.
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Affiliation(s)
- Kylene M. Harold
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | | | | | | | - Kaitlyn Hill
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Alex X. Arreola
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Malika Sekhri
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Steven Carter
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Jorge Gomez-Gutierrez
- Department of Child Health, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - George Salem
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Girish Mishra
- Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Lacey R. McNally
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Balk EM, Adam GP, Cao W, Mehta S, Shah N. Evaluation and Management After Acute Left-Sided Colonic Diverticulitis : A Systematic Review. Ann Intern Med 2022; 175:388-398. [PMID: 35038269 DOI: 10.7326/m21-1646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The value of interventions used after acute colonic diverticulitis is unclear. PURPOSE To evaluate postdiverticulitis colonoscopy and interventions to prevent recurrent 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 Comparative studies of interventions of interest reporting critical or important outcomes, and larger single-group studies to evaluate prevalence of colonoscopy findings and harms. DATA EXTRACTION 6 researchers extracted study data and risk of bias. The team assessed strength of evidence. DATA SYNTHESIS 19 studies evaluated colonoscopy. Risk for prevalent colorectal cancer (CRC) compared with the general population is unclear. Based on low-strength evidence, long-term CRC diagnosis is similar with or without colonoscopy. High-strength evidence indicates that risk for prevalent CRC is higher among patients with complicated diverticulitis and colonoscopy complications are rare. Based on high-strength evidence, mesalamine does not reduce recurrence risk (6 randomized controlled trials [RCTs]). Evidence on other nonsurgical interventions is insufficient. For patients with prior complicated or smoldering or frequently recurrent diverticulitis, elective surgery is associated with reduced recurrence (3 studies; high strength). In 19 studies, serious surgical complications were uncommon. LIMITATIONS Few RCTs provided evidence. Heterogeneity of treatment effect was not adequately assessed. CONCLUSION It is unclear whether patients with recent acute diverticulitis are at increased risk for prevalent CRC, but those with complicated diverticulitis are at increased risk. Mesalamine is ineffective in preventing recurrence; other nonsurgical treatments have inadequate evidence. Elective surgery reduces recurrence in patients with prior complicated or smoldering or frequently recurrent diverticulitis, but it is unclear which of these patients may benefit most. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).
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Affiliation(s)
- Ethan M Balk
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., W.C., S.M.)
| | - Gaelen P Adam
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., W.C., S.M.)
| | - Wangnan Cao
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., W.C., S.M.)
| | - Shivani Mehta
- Brown Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island (E.M.B., G.P.A., W.C., S.M.)
| | - Nishit Shah
- Warren Alpert Medical School at Brown University, Providence, Rhode Island (N.S.)
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Thornblade LW, Simianu VV, Davidson GH, Flum DR. Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy. Ann Surg 2021; 273:1157-1164. [PMID: 31651534 PMCID: PMC7174092 DOI: 10.1097/sla.0000000000003639] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence. BACKGROUND While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks. METHODS Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014). RESULTS Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%]. CONCLUSIONS Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.
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The Immediate, Hospital-Level Impact of Stay-at-Home Order on Diverticulitis Burden. J Gastrointest Surg 2021; 25:533-535. [PMID: 32930916 PMCID: PMC7491357 DOI: 10.1007/s11605-020-04798-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/06/2020] [Indexed: 01/31/2023]
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Lauro A, Pozzi E, Vaccari S, Cervellera M, Tonini V. Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis. Dig Dis Sci 2020; 65:3463-3476. [PMID: 32980955 DOI: 10.1007/s10620-020-06621-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Augusto Lauro
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Eleonora Pozzi
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Samuele Vaccari
- Department of Surgical Sciences, Umberto I University Hospital - La Sapienza, Rome, Italy.
| | - Maurizio Cervellera
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
| | - Valeria Tonini
- Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
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Rai V, Mishra N. Surgical Management of Recurrent Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2020; 34:91-95. [PMID: 33642948 DOI: 10.1055/s-0040-1716700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.
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Affiliation(s)
- Vinay Rai
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Nitin Mishra
- Department of Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
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Abstract
BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).
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Brandl A, Kratzer T, Kafka-Ritsch R, Braunwarth E, Denecke C, Weiss S, Atanasov G, Sucher R, Biebl M, Aigner F, Pratschke J, Öllinger R. Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach? Can J Surg 2017; 59:254-61. [PMID: 27240131 DOI: 10.1503/cjs.012915] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes. METHODS This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated. RESULTS Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis. CONCLUSION Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.
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Affiliation(s)
- Andreas Brandl
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Theresa Kratzer
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Reinhold Kafka-Ritsch
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Eva Braunwarth
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Christian Denecke
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Sascha Weiss
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Georgi Atanasov
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Robert Sucher
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Matthias Biebl
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Felix Aigner
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Johann Pratschke
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
| | - Robert Öllinger
- From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger)
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Schlussel A, Steele SR. Statewide quality improvement initiatives in colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Barroso AO, Quigley EMM. Diverticula and Diverticulitis: Time for a Reappraisal. Gastroenterol Hepatol (N Y) 2015; 11:680-688. [PMID: 27330495 PMCID: PMC4849520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Colonic diverticula are very common and may be associated with symptoms or complicated by diverticulitis and its associated problems. Many of the traditional concepts relating to the pathophysiology, prevention, and management of these entities have been questioned recently based on findings from high-quality prospective studies. Although dietary fiber may protect against symptoms and complications, its impact on the formation of diverticula may be limited. It is now evident that the risk for an episode of diverticulitis in an individual with diverticula is lower than previously thought. Furthermore, the necessity for antibiotic use in uncomplicated diverticulitis has been questioned and serious doubt cast upon the belief that surgery should be performed when a second attack occurs. Although data are far from conclusive, there is some evidence to suggest that diverticulosis may be associated with chronic abdominal symptoms, with or without underlying chronic inflammatory changes in the involved segment of the colon. In addition, colonoscopy is not routinely required after an attack of acute uncomplicated diverticulitis, as the risk of cancer in this population is not much higher than in the general population.
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Affiliation(s)
- Alberto O Barroso
- Dr Barroso is an associate professor and Dr Quigley is a professor in the Division of Gastroenterology and Hepatology at the Lynda K. and David M. Underwood Center for Digestive Disorders at Houston Methodist Hospital and Weill Cornell Medical College in Houston, Texas
| | - Eamonn M M Quigley
- Dr Barroso is an associate professor and Dr Quigley is a professor in the Division of Gastroenterology and Hepatology at the Lynda K. and David M. Underwood Center for Digestive Disorders at Houston Methodist Hospital and Weill Cornell Medical College in Houston, Texas
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