Acute Diverticulitis in Elderly Patients: Does Age Really Matter?

The role of procalcitonin as a risk stratification tool of severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis

BACKGROUND

Imaging-based classifications do not always reflect the clinical severity and prognosis of acute left-sided colonic diverticulitis. This study aims to investigate the role of an early procalcitonin assessment in the emergency department as a risk stratification tool for severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis.

METHODS

In this retrospective cohort study, all adult patients consecutively admitted from January 2015 to September 2020 for acute left-sided colonic diverticulitis and having a procalcitonin determination at admission were enrolled. The following data were collected: age, sex, comorbidities, laboratory parameters, level of urgency, clinical presentation, type of treatment, complications, and post-management outcomes. The association between the procalcitonin value at admission and the following endpoints was analyzed: type of treatment, classification of acute left-sided colonic diverticulitis, mortality, and type of surgery.

RESULTS

A total of 503 consecutive patients were enrolled. Procalcitonin >0.5 ng/mL emerged as an independent risk factor for complicated acute left-sided colonic diverticulitis (P = .007). Procalcitonin >0.5 ng/mL (P = .033), together with a history of complicated acute left-sided colonic diverticulitis (P < .001), abdominal pain (P = .04), bowel perforation (P < .001), and peritonitis (P < .001), was a significant risk factor for surgery. Procalcitonin >0.5 ng/mL (P = .007) and peritonitis (P = .03) emerged as independent risk factors for sigmoidectomy without colorectal anastomosis. Procalcitonin >0.5 ng/mL (P = .004), a higher level of urgency at admission (P = .005), Hartmann's procedure (P = .002), and the necessity of mechanical ventilation (P = .004) emerged as independent risk factors for mortality.

CONCLUSION

Procalcitonin >0.05 ng/mL at emergency department admission is a useful risk stratification tool for severity, prognosis, and need for surgical treatment in patients with acute left-sided colonic diverticulitis.

Recurrence of severe diverticulitis is associated with age and birth decade

BACKGROUND

The risk of recurrence is an important consideration when deciding to treat patients medically or with elective colectomy after recovery from diverticulitis. It is unclear whether age is associated with recurrence. This study aimed to examine the relationship between age and the risk of recurrent diverticulitis while considering important epidemiologic factors, such as birth decade.

METHODS

The Utah Population Database was used to identify individuals with incident severe diverticulitis, defined as requiring an emergency department visit or hospitalization, between 1998 and 2018. This study measured the relationship between age and recurrent severe diverticulitis after adjusting for birth decade and other important variables, such as sex, urban/rural status, complicated diverticulitis, and body mass index using a Cox proportional hazards model.

RESULTS

The cohort included 8606 individuals with a median age of 61 years at index diverticulitis diagnosis. After adjustment, among individuals born in the same birth decade, increasing age at diverticulitis onset was associated with an increased risk of recurrent diverticulitis (hazard ratio [HR] for 10 years, 1.8; 95% CI, 1.5-2.1). Among individuals with the same age of onset, those born in a more recent birth decade were also at greater risk of recurrent diverticulitis (HR, 1.9; 95% CI, 1.6-2.3).

CONCLUSION

Among individuals with an index episode of severe diverticulitis, recurrence was associated with increasing age and more recent birth decade. Clinicians may wish to employ age-specific strategies when counseling patients regarding treatment options after a diverticulitis diagnosis.

Diverticulitis in Older Adults: Is Cognitive Impairment Associated With Outcomes?

INTRODUCTION

Older age is associated with increased prevalence of both diverticulitis and cognitive impairment. The association between cognitive impairment and outcomes among older adults presenting to the emergency department (ED) for diverticulitis is unknown.

METHODS

Adults aged ≥65 y presenting to an ED with a primary diagnosis of colonic diverticulitis were identified using the Nationwide Emergency Department Sample (2016-2019) and stratified by cognitive impairment status in this retrospective cohort study. Multivariable Poisson regression models adjusted for patient age, sex, Elixhauser Comorbidity Index, primary payer status, and presence of complicated diverticulitis quantified relative risk of a) inpatient admission, b) operative intervention, and c) in-hospital mortality comparing patients with or without a diagnosis code suggestive of cognitive impairment.

RESULTS

Among 683,444 older adults with an ED encounter for diverticulitis from 2016 to 2019, there were 468,226 patients with isolated colonic diverticulitis and 26,388 (5.6%) with comorbid cognitive impairment. After adjustment, the risk of inpatient admission for those with cognitive impairment was 18% higher than for those without cognitive impairment (adjusted relative risks [aRR]: 1.18, 95% confidence interval [CI]: 1.17-1.20). Those with cognitive impairment were 34% more likely to undergo colectomy than those without cognitive impairment (aRR: 1.34, 95% CI: 1.24-1.44). Older adults with cognitive impairment had a 32% greater mortality than those without cognitive impairment (aRR: 1.32, 95% CI: 1.05-1.67).

CONCLUSIONS

Among older adults presenting for ED care with a primary diagnosis of colonic diverticulitis, individuals with cognitive impairment had higher rates of hospitalization, operative intervention, and in-hospital mortality than those without cognitive impairment.

Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure

OBJECTIVES

To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population.

DESIGN

Retrospective multi-institute database cohort analysis.

SETTINGS AND PARTICIPANTS

American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65 years, 65-79 years, ≥80 years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression.

RESULTS

A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79 years [odds ratio (OR) 2.39, P < .001] and ≥80 years (OR 6.28, P < .001) compared to patients aged <65 years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80 years (OR 2.63, P = .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79 years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P = .001). In patients aged ≥80 years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P = .04). Thirty-day mortality was also lower in patients aged ≥80 years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P = .03) but similar for patients aged 65-79 years (OR 0.81, P = .70).

CONCLUSION AND IMPLICATIONS

In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80 years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.

Gastric emergencies in older adults: not always the same old story! A tertiary care emergency department observational cohort study

OBJECTIVE

To analyse and compare the clinical outcomes between patients ≥80 years and 65-79 years, who presented to our emergency department (ED) with the two most common gastric emergency (GE) clinical presentation, that is, gastric bleeding and gastric perforation.

DESIGN

Single-centre retrospective cohort study.

PARTICIPANTS

A total of 1011 patients were enrolled: 421 patients aged ≥80 years were compared with a group of 590 patients aged 65-79 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was to compare the overall mortality. Secondary outcomes included major complications, in-hospital length of stay (LOS) and need for surgical procedures.

RESULTS

Patients ≥80 years with GE had different presentations at ED compared with younger patients: they had higher gastrointestinal bleeding (24.9% vs 16.3%, p=0.001), anemisation (14.5% vs 8.8%, p=0.005) and shock (10.9% vs 5.1%, p=0.001) rates. Median LOS, cumulative major complications and mortality rates were similar among the two groups.Multivariate analysis identified shock, gastric malignancy and gastric fistula as independent predictors for survival.

CONCLUSIONS

Patients ≥80 years with GE did not have a higher mortality rate and cumulative major complications as compared to younger elderly patients. Invasive treatments were not associated with a different prognosis in this age group.

One-Year Outcomes Following Emergency Laparotomy: A Systematic Review

BACKGROUND

Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL.

METHOD

A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed.

RESULTS

Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%.

CONCLUSION

The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.