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Annals of Internal Medicine Mar 2022Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.
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).
Topics: Acute Disease; Anti-Bacterial Agents; Diagnostic Imaging; Diverticulitis; Diverticulitis, Colonic; Humans
PubMed: 35038271
DOI: 10.7326/M21-1645 -
Frontiers in Medicine 2022Diverticular disease of the colon represents a common clinical condition in the western world. Its prevalence increases with age and only 5% of cases occur in adults...
BACKGROUND
Diverticular disease of the colon represents a common clinical condition in the western world. Its prevalence increases with age and only 5% of cases occur in adults younger than 40 years of age, making it a rare condition during pregnancy. The aim of this review was to provide an overview of the reported cases of diverticulitis during pregnancy.
METHODS
We conducted a systematic review of the literature based on preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. We searched three different electronic databases namely PubMed, Scopus and Web of Science from inception to December 2021. Literature search and data extraction were completed in duplicates.
RESULTS
The initial search yielded 564 articles from which 12 were finally included in our review. Ten articles were case reports and two were observational studies. The mean age of the cases was 34 years. The presenting complain was provided for 11 cases. The majority of the patients (10/11, 91%) presented with abdominal pain located mainly on the left (6/11, 55%) or right (4/11, 36%) iliac fossa. The most common diagnostic modality used for the diagnosis of the condition was ultrasonography in nine cases (9/12, 75%) followed by magnetic resonance imaging (MRI) in two cases (2/12, 17%). In spite of clinical and radiological evaluation, the initial diagnosis was inaccurate in seven cases (7/12, 58%). The therapeutic approach was available for 11 cases and it was based on the administration of intravenous antibiotics in six cases (6/11, 55%) and surgical management in five cases (5/11, 45%). Data for the type of delivery was provided in nine studies with five patients (5/9, 56%) delivering vaginally and four patients (4/9, 44%) delivering with cesarean section.
CONCLUSION
As advanced maternal age becomes more common, the frequency of diverticulitis in pregnancy may increase. Although available guidelines do not exist, the clinical awareness, early recognition of the disorder, using diagnostic modalities such as ultrasound and MRI, and rapid therapeutic approach with antibiotics, may improve maternal and neonatal outcomes.
PubMed: 36438049
DOI: 10.3389/fmed.2022.942666 -
International Journal of Surgery... Oct 2018No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We... (Meta-Analysis)
Meta-Analysis
BACKGROUND
No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature.
METHODS
Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted.
RESULTS
The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%.
CONCLUSION
Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.
Topics: Adult; Anastomosis, Surgical; Bias; Diverticulitis, Colonic; Humans; Intestinal Perforation; Morbidity; Prospective Studies; Retrospective Studies
PubMed: 30165109
DOI: 10.1016/j.ijsu.2018.08.009 -
International Journal of Colorectal... May 2017Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis. Until now, a comprehensive systematic overview and evaluation of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis. Until now, a comprehensive systematic overview and evaluation of relevant risk factors have not been presented. This review aimed at assembling and evaluating current evidence on risk factors for recurrence after conservatively treated acute colonic diverticulitis.
METHODS
PubMed, Embase, and Cochrane databases were searched for studies evaluating risk factors for recurrence after acute diverticulitis treated non-surgically defined as antibiotic treatment, percutaneous abscess drainage, or by observation. Randomized clinical trials and observational studies were included. Analyzed outcome variables were extracted and grouped. No meta-analysis was performed due to low inter-study comparability. Variables were rated according to their likelihood of causing recurrence (no/low, medium, high).
RESULTS
Of 1153 screened records, 35 studies were included, enrolling 396,676 patients with acute diverticulitis. A total of 50,555 patients experienced recurrences. Primary diverticulitis with abscess formation and young age increased the risk of recurrence. Readmission risk was higher within the first year after remission. In addition, the risk of subsequent diverticulitis more than doubled after two earlier episodes of diverticulitis and the risk increased further for every episode.
CONCLUSIONS
The best treatment strategy for recurrent diverticulitis is undetermined. However, the risk of a new recurrence seemed to increase after each recurrence making elective resection a viable option at some point after multiple recurrences depending on patient risk factors and preferences.
Topics: Abscess; Acute Disease; Adult; Aged; Body Mass Index; Diverticulitis, Colonic; Female; Humans; Inflammation; Male; Middle Aged; Recurrence; Risk Factors; Time Factors
PubMed: 28110383
DOI: 10.1007/s00384-017-2766-z -
World Journal of Emergency Surgery :... Nov 2022There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.
METHODS
A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.
RESULTS
Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8-13%, I = 86%, p < 0.01) in right-sided and 20% (95% CI 16-24%, I = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6-13%, I = 77%, p < 0.01) in right-sided and 15% (95% CI 8-27%, I = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2-10%, I = 84%, p < 0.01) in right-sided and 4% (95% CI 2-7%, I = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.
CONCLUSION
Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.
Topics: Humans; Diverticulitis, Colonic; Risk Factors; Anti-Bacterial Agents
PubMed: 36320045
DOI: 10.1186/s13017-022-00463-7 -
International Journal of Surgery... Oct 2017To investigate outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis. (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
To investigate outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis.
METHODS
We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of early versus delayed surgery in patients with acute recurrent diverticulitis. We used the Newcastle-Ottawa scale to assess the risk of bias of included studies. Random-effects models were applied to calculate pooled outcome data.
RESULTS
We identified three retrospective and one prospective cohort studies enrolling a total of 1046 patients. The included patients were comparable in terms of age, ASA score and Hinchey classifications (Hinchey I and II). The results of our analyses suggested that there was no difference between two groups in surgical site infection [Odds ratio (OR) 1.61, 95% CI 0.79-3.27, P = 0.19], intra-abdominal abscess (OR 0.92, 95% CI 0.21-4.00, P = 0.91), anastomotic leak (OR1.27, 95% CI 0.50-3.25, P = 0.61), 30-day mortality [Risk difference (RD) 0.00 95% CI -0.01-0.01, P = 0.80], postoperative ileus (OR 1.35, 95% CI 0.50-3.66, P = 0.55), postoperative bleeding (OR 0.93, 95% CI 0.32-2.69, P = 0.89), ureteric injury (OR 0.62, 95% CI 0.08-5.07, P = 0.65), and overall morbidity (OR 1.42 95% CI 0.76-2.66, P = 0.27). The early surgery was associated with longer operative time [Mean Difference (MD) 12.8, 95% CI 5.08-20.53, P = 0.001] and length of stay (MD 4.41, 95% CI -0.34-8.53, P = 0.03). Among those undergoing laparoscopic surgery, conversion to open surgery was higher in the early surgery group (OR 2.71, 95% CI 1.36-5.40, P = 0.005).
CONCLUSIONS
The best available evidence suggests that there is no difference between early elective and delayed elective surgery for acute recurrent diverticulitis in terms of clinical outcomes. However, longer operative time and length of stay and higher conversion rate to open surgery associated with early elective surgery may make the delayed elective surgery more cost-effective. The best available evidence is derived from non-randomised studies; therefore, high quality randomised controlled trials are required to provide more robust basis for definite conclusions.
Topics: Abdominal Abscess; Acute Disease; Diverticulitis; Elective Surgical Procedures; Humans; Laparoscopy; Postoperative Complications; Recurrence
PubMed: 28882772
DOI: 10.1016/j.ijsu.2017.08.583 -
Surgical Laparoscopy, Endoscopy &... Oct 2022Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze...
PURPOSE
Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze contemporary literature data to appraise the current standard of care and changes of treatment algorithms over time.
MATERIALS AND METHODS
A systematic review of the literature on surgical management of CVF was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines.
RESULTS
Fourteen papers published between 2014 and 2020 and including 1061 patients were analyzed. One-stage colonic resection with primary anastomosis, with or without loop ileostomy, was the most common surgical procedure. A laparoscopic or robotic approach was attempted in 39.5% of patients, and conversion rate to open surgery was 7.8%. Clavien-Dindo grade ≥3 complication rate, 30-day mortality, and recurrence rate were 7.4%, 1.5%, and 0.5%, respectively.
CONCLUSIONS
Minimally invasive sigmoidectomy with primary anastomosis is safe and should be the first-choice approach for CVF. Bladder repair is not necessary after a negative intraoperative leak test. A standardized perioperative care can improve clinical outcomes and reduce the length of hospital stay and the duration of Foley catheterization.
Topics: Colon, Sigmoid; Conversion to Open Surgery; Diverticulitis, Colonic; Humans; Intestinal Fistula; Laparoscopy; Postoperative Complications; Quality of Life; Treatment Outcome
PubMed: 36044282
DOI: 10.1097/SLE.0000000000001099 -
Clinical Gastroenterology and... Feb 2016Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND & AIMS
Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.
METHODS
We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854).
RESULTS
We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment.
CONCLUSIONS
On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality.
Topics: Cohort Studies; Diverticulitis; Humans; Patient Satisfaction; Quality of Life; Recurrence; Treatment Outcome
PubMed: 26305068
DOI: 10.1016/j.cgh.2015.08.020 -
Techniques in Coloproctology Feb 2017This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A... (Comparative Study)
Comparative Study Meta-Analysis Review
This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34-4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02-0.51), and a shorter length of postoperative hospital stay during index admission (WMD = -2.03, 95% CI -2.59 to -1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30-90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien-Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38-0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.
Topics: Abdominal Abscess; Adolescent; Adult; Aged; Aged, 80 and over; Diverticulitis; Female; Humans; Intestinal Perforation; Intestines; Laparoscopy; Length of Stay; Male; Middle Aged; Peritoneal Lavage; Peritonitis; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Severity of Illness Index; Surgical Stomas; Treatment Outcome; Young Adult
PubMed: 28197792
DOI: 10.1007/s10151-017-1585-0 -
International Journal of Colorectal... Apr 2023Antibiotics have long been recommended as a form of conservative therapy in patients with acute uncomplicated diverticulitis despite no supporting evidence. This... (Meta-Analysis)
Meta-Analysis
PURPOSE
Antibiotics have long been recommended as a form of conservative therapy in patients with acute uncomplicated diverticulitis despite no supporting evidence. This meta-analysis aims to assess the difference in outcomes between observational therapy and antibiotics regime in patients with acute uncomplicated diverticulitis.
METHODS
Medline and Embase electronic databases were reviewed. A comparative meta-analysis in odds ratios (ORs) or mean difference (MD) was conducted using a random effects model for dichotomous and continuous outcomes, respectively. Randomized controlled trials comparing outcomes in patients with acute uncomplicated diverticulitis on observational therapy compared to antibiotics regime were selected. Outcomes of interest included all-cause mortality, complications, emergency surgery rates, length of stay, and recurrence.
RESULTS
A total of 7 articles looking at 5 different randomized controlled trials were included. A total of 2959 patients with acute uncomplicated diverticulitis comprising of 1485 patients on antibiotics therapy and 1474 patients on observational therapy were included in the comparison. We found that there was no statistically significant difference in all-cause mortality (OR = 0.98; 95% CI 0.53;1.81; p = 0.68), complications (OR = 1.04; 95% CI 0.36;3.02; p = 0.51), emergency surgery (OR = 1.24; 95% CI 0.70;2.19, p = 0.92), length of stay (M.D: -0.14, 95% CI -0.50;0.23, p < 0.001), and recurrent diverticulitis (OR 1.01; 95% CI 0.83;1.22, p < 0.91) between the two arms.
CONCLUSION
This systemic review and meta-analysis found that there is no statistically significant difference in outcomes between patients with acute uncomplicated diverticulitis who were put on observational therapy compared to the antibiotics regime. This suggests that observational therapy is an equally safe and effective therapy as compared to antibiotics therapy.
Topics: Humans; Anti-Bacterial Agents; Diverticulitis; Conservative Treatment; Acute Disease; Diverticulitis, Colonic; Treatment Outcome; Observational Studies as Topic
PubMed: 37059809
DOI: 10.1007/s00384-023-04389-7