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Langenbeck's Archives of Surgery Jun 2018Surgical strategies for perforated diverticulitis (Hinchey stages III and IV) remain controversial. This systematic review aimed to compare the outcome of primary... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Surgical strategies for perforated diverticulitis (Hinchey stages III and IV) remain controversial. This systematic review aimed to compare the outcome of primary anastomosis, Hartmann procedure and laparoscopic lavage.
METHODS
A systematic literature search was conducted through Medline, Embase, Cochrane Central Register and Health Technology Assessment Database to identify randomized and non-randomized controlled trials involving patients with perforated left-sided colonic diverticulitis comparing different surgical strategies. The methodological quality of the included studies was assessed systematically (Grading of Recommendations, Assessment, Development and Evaluation) and a meta-analysis was performed.
RESULTS
After screening 4090 titles and abstracts published between 1958 and January 2018, 148 were selected for full text assessment. Sixteen trials (7 RCTs, 9 non-RCTs) with 1223 patients were included. Mortality rates were not significantly different between Hartmann procedure and primary anastomosis for Hinchey III and IV, neither in the meta-analysis of three RCTs (RR 2.03 (95% CI 0.79 to 5.25); p = 0.14, moderate quality of evidence) nor in the meta-analysis of six observational studies (RR 1.53 (95% CI 0.89 to 2.65); p = 0.13, very low quality of evidence). However, stoma reversal rates were significantly higher in the primary anastomosis group (RR 0.73 (95% CI 0.58 to 0.98); p = 0.008, moderate quality of evidence). Meta-analysis of four RCTs showed no significant difference between laparoscopic lavage for Hinchey III compared to sigmoid resection neither for mortality (RR 1.07 (95% CI 0.65 to 1.76); p = 0.79, moderate quality of evidence) nor for major complications (RR 0.86 (95% CI 0.69 to 1.08); p = 0.20, moderate quality of evidence).
CONCLUSIONS
This systematic review suggests similar rates of complications but higher rates of colonic restoration after primary anastomosis compared to Hartmann procedure in perforated diverticulitis with generalized peritonitis (Hinchey III and IV). Results in laparoscopic lavage for Hinchey III are not superior to primary resection. However, further studies with a careful interpretation of the meaning of re-interventions are required.
Topics: Anastomosis, Surgical; Diverticulitis, Colonic; Humans; Intestinal Perforation; Laparoscopy; Peritonitis; Therapeutic Irrigation
PubMed: 29931505
DOI: 10.1007/s00423-018-1686-x -
International Journal of Colorectal... Aug 2020The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating... (Meta-Analysis)
Meta-Analysis Review
Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis.
PURPOSE
The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence.
METHODS
A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs).
RESULTS
From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients.
CONCLUSION
Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.
Topics: Adult; Anastomosis, Surgical; Colon, Sigmoid; Colostomy; Diverticulitis; Diverticulitis, Colonic; Humans; Intestinal Perforation; Peritonitis; Treatment Outcome
PubMed: 32504331
DOI: 10.1007/s00384-020-03617-8 -
The Surgeon : Journal of the Royal... Dec 2021Ultrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating... (Review)
Review
BACKGROUND
Ultrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating this skill into their clinical practice. This systematic review provides an up-to-date summary of the evidence for abdominal ultrasound scans performed by general surgeons to diagnose intra-abdominal pathology.
METHODS
Two independent reviewers searched the PubMed database between 1 January 1980 and 1 June 2020. Articles about surgeon-performed abdominal ultrasound in adult patients were included. Studies on trauma and vascular surgery were excluded.
RESULTS
26 articles met the inclusion criteria, presented as a narrative analysis. There was good evidence for the use of surgeon-performed ultrasound, particularly in gallstone-related diseases and moderate evidence for the use of ultrasound in appendicitis. Further evidence is required for point-of-care ultrasounds for other pathologies such as diverticulitis and groin hernias. Ultrasound training for general surgeons is variable with notable heterogeneity across studies.
CONCLUSION
A standardised training programme for general surgeons will greatly improve confidence and skill. There is good evidence for the use of bedside ultrasound by general surgeons in the acute and elective setting with reduced time to definitive treatment and fewer unnecessary hospital admissions.
Topics: Adult; Appendicitis; Hernia, Inguinal; Humans; Point-of-Care Systems; Surgeons; Ultrasonography
PubMed: 33692002
DOI: 10.1016/j.surge.2021.01.014 -
Journal of Digestive Diseases Feb 2020Acute perforated diverticulitis is frequently observed and spans a spectrum in the severity of its presentation. Emergency surgery is required in patients with...
OBJECTIVE
Acute perforated diverticulitis is frequently observed and spans a spectrum in the severity of its presentation. Emergency surgery is required in patients with generalized peritonitis; however, a large proportion of patients are clinically stable with localized peritonitis. This article aimed to examine this specific group of patients by reviewing the outcomes of their conservative management.
METHODS
A systematic literature search was performed on the MEDLINE and PubMed databases. The management outcomes of patients undergoing non-operative treatment for acute perforated diverticulitis were synthesized and tabulated.
RESULTS
Of 479 patients, 407 (85%) were successfully managed non-operatively. In total 70 (14.6%) patients failed non-operative treatment and underwent operative surgical management, and two (0.4%) died. Emergency surgery includes a Hartmann's operation (40%) and resection with anastomosis with or without stoma (24%), laparoscopic lavage (16%) and surgical drainage (20%). The success rate of conservative management was 94.0% and 71.4% for patients with pericolic and distant free air, respectively. Treatment failure was associated with a high volume of free air, distant free air and the presence of abscess.
CONCLUSIONS
Conservative management is safe and successful in patients with acute perforated diverticulitis without generalized peritonitis. The early recognition of patients who show clinical signs of persistent perforation is important to ensure the success of this strategy.
Topics: Acute Disease; Adult; Aged; Conservative Treatment; Diverticulitis; Female; Humans; Intestinal Perforation; Male; Middle Aged; Peritonitis; Treatment Outcome
PubMed: 31875348
DOI: 10.1111/1751-2980.12838 -
Diseases of the Colon and Rectum Aug 2019Antibiotics are routinely used for diverticulitis irrespective of severity. Current practice guidelines favor against the use of antibiotics for acute uncomplicated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Antibiotics are routinely used for diverticulitis irrespective of severity. Current practice guidelines favor against the use of antibiotics for acute uncomplicated diverticulitis.
OBJECTIVE
We performed a systematic review and meta-analysis to examine the role of antibiotic use in an episode of uncomplicated diverticulitis.
DATA SOURCES
PubMed/Medline, Embase, Scopus, and Cochrane were used.
STUDY SELECTION
Eligible studies included those with patients with uncomplicated diverticulitis receiving any antibiotics compared with patients not receiving any antibiotics (or observed alone).
MAIN OUTCOME MEASURES
Pooled odds rate of total complications, treatment failure, recurrent diverticulitis, readmission rate, sigmoid resection, mortality rate, and length of stay were measured.
RESULTS
Of 1050 citations reviewed, 7 studies were eligible for the analysis. There were total of 2241 patients: 895 received antibiotics (mean age = 59.1 y; 38% men) and 1346 did not receive antibiotics (mean age = 59.4 y; 37% men). Antibiotics were later added in 2.7% patients who initially were observed off antibiotics. Length of hospital stay was not significantly different among either group (no antibiotics = 3.1 d vs antibiotics = 4.5 d; p = 0.20). Pooled rate of recurrent diverticulitis was not significantly different among both groups (pooled OR = 1.27 (95%, CI 0.90-1.79); p = 0.18). Rate of total complications (pooled OR = 1.99 (95% CI, 0.66-6.01); p = 0.22), treatment failure (pooled OR = 0.68 (95% CI, 0.42-1.09); p = 0.11), readmissions (pooled OR = 0.75 (95% CI, 0.44-1.30); p = 0.31). and patients who required sigmoid resection (pooled OR = 3.37 (95% CI, 0.65-17.34); p = 0.15) were not significantly different among patients who received antibiotics and those who did not. Mortality rates were 4 of 1310 (no-antibiotic group) versus 4 of 863 (antibiotic group).
LIMITATIONS
Only 2 randomized controlled studies were available and there was high heterogeneity in existing data.
CONCLUSIONS
This meta-analysis of current literature shows that patients with uncomplicated diverticulitis can be monitored off antibiotics.
Topics: Acute Disease; Anti-Bacterial Agents; Diverticulitis, Colonic; Humans
PubMed: 30664553
DOI: 10.1097/DCR.0000000000001324 -
Annals of Surgery Apr 2017To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis.
BACKGROUND
Peritonitis secondary to perforated diverticulitis has conventionally been managed by resection and stoma formation. Case series have suggested that patients can be safely managed with laparoscopic lavage, resulting in reduced mortality and stoma formation. Recently, 3 randomized controlled trials have published contradictory conclusions.
METHODS
MEDLINE from 1946 to present, Cochrane Database of Systematic Reviews, and Cochrane database of Registered clinical trials and EMBASE (all via OVID) were searched using the terms "laparoscopy" AND ("primary resection" OR "Hartmann procedure", OR "sigmoidectomy"), AND "Diverticulitis", AND "Peritonitis" AND "therapeutic irrigation" or "lavage" AND randomized controlled trial and any derivatives of those terms. We included all randomized controlled trials. Data were extracted from each study using a purpose-designed template. Statistical analysis was undertaken using Revman 5.
RESULTS
Three randomized controlled trials were identified from 48 potential studies. The analysis included 307 patients of whom 159 underwent laparoscopic lavage. Overall, the rate of reintervention within 30 days postoperatively was 45/159 (28.3%) in the lavage group and 13/148 (8.8%) in the resection group (relative risk 3.01, 95% confidence interval 1.15-7.90). There was no significant difference in Intensive Care Unit admissions, 30 and 90-day mortality, or stoma rates at 12 months.
CONCLUSION
Laparoscopic lavage used in the management of Hinchey grade III diverticulitis leads to more reinterventions within 30 days postoperatively, but does not increase the 30 or 90-day mortality rates compared with sigmoid resection.
Topics: Diverticulitis; Diverticulum, Colon; Female; Hospital Mortality; Humans; Laparoscopy; Male; Peritoneal Lavage; Peritonitis; Prognosis; Randomized Controlled Trials as Topic; Risk Assessment; Severity of Illness Index; Survival Rate; Treatment Outcome
PubMed: 27631772
DOI: 10.1097/SLA.0000000000002005 -
Digestive Diseases and Sciences Mar 2016Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical... (Review)
Review
BACKGROUND
Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical management of diverticulitis has undergone significant changes in recent years. This article reviews the role of minimally invasive approach in management of complicated diverticulitis, with a focus on recent concepts and advances.
MATERIALS AND METHODS
A literature review of past 10 years (January 2004 to September 2014) was performed using the electronic database MEDLINE from PubMed which included articles only in English.
RESULTS
We identified total of 139 articles, out of which 50 were excluded resulting in 89 full-text articles for review 16 retrospective studies, 7 prospective cohorts, 1 case-control series and 1 systematic review were included. These suggest that urgent surgery is performed for those with sepsis and diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage. In addition, 3 randomized control trials: DILALA, LapLAND and the Scandinavian Diverticulitis trial are working towards evaluating whether laparoscopic lavage is safe in management of complicated diverticular diseases. Growing trend toward conservative or minimally invasive treatment modality even in severe acute diverticulitis was noticed.
CONCLUSIONS
Laparoscopic peritoneal lavage has evolved as a good alternative to invasive surgery, yet clear indications for its role in the management of complicated diverticulitis need to be established. Recent evidence suggests that existing guidelines for optimal management of complicated diverticulitis should be updated. Non-resectional radiographic techniques are likely to play a prominent role in the initial treatment of complicated diverticulitis in the near future.
Topics: Abdominal Abscess; Colectomy; Disease Management; Diverticulitis; Drainage; Humans; Intestinal Perforation; Laparoscopy; Minimally Invasive Surgical Procedures; Peritoneal Lavage; Peritonitis; Severity of Illness Index; Surgery, Computer-Assisted
PubMed: 26547753
DOI: 10.1007/s10620-015-3924-1 -
Journal of Gastroenterology and... Jul 2023The role of the microbiota in diverticulosis and diverticular disease is underexplored. This systematic review aimed to assess all literature pertaining to the... (Review)
Review
BACKGROUND AND AIMS
The role of the microbiota in diverticulosis and diverticular disease is underexplored. This systematic review aimed to assess all literature pertaining to the microbiota and metabolome associations in asymptomatic diverticulosis, symptomatic uncomplicated diverticular disease (SUDD), and diverticulitis pathophysiology.
METHODS
Seven databases were searched for relevant studies published up to September 28, 2022. Data were screened in Covidence and extracted to Excel. Critical appraisal was undertaken using the Newcastle Ottawa Scale for case/control studies.
RESULTS
Of the 413 papers screened by title and abstract, 48 full-text papers were reviewed in detail with 12 studies meeting the inclusion criteria. Overall, alpha and beta diversity were unchanged in diverticulosis; however, significant changes in alpha diversity were evident in diverticulitis. A similar Bacteroidetes to Firmicutes ratio compared with controls was reported across studies. The genus-level comparisons showed no relationship with diverticular disease. Butyrate-producing microbial species were decreased in abundance, suggesting a possible contribution to the pathogenesis of diverticular disease. Comamonas species was significantly increased in asymptomatic diverticulosis patients who later developed diverticulitis. Metabolome analysis reported significant differences in diverticulosis and SUDD, with upregulated uracil being the most consistent outcome in both. No significant differences were reported in the mycobiome.
CONCLUSION
Overall, there is no convincing evidence of microbial dysbiosis in colonic diverticula to suggest that the microbiota contributes to the pathogenesis of asymptomatic diverticulosis, SUDD, or diverticular disease. Future research investigating microbiota involvement in colonic diverticula should consider an investigation of mucosa-associated microbial changes within the colonic diverticulum itself.
Topics: Humans; Diverticulum, Colon; Diverticulosis, Colonic; Microbiota; Diverticulitis; Diverticular Diseases
PubMed: 36775316
DOI: 10.1111/jgh.16142 -
Colorectal Disease : the Official... Jul 2017This systematic review and meta-analysis aimed to clarify whether tobacco smoking is associated with an increased risk of diverticular disease. (Meta-Analysis)
Meta-Analysis Review
AIM
This systematic review and meta-analysis aimed to clarify whether tobacco smoking is associated with an increased risk of diverticular disease.
METHOD
The PubMed and Embase databases were searched for studies of smoking and diverticular disease up to 19 February 2016. Prospective studies that reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of diverticular disease associated with current or previous smoking were included. Summary RRs were estimated using a random effects model.
RESULTS
We identified five prospective studies which comprised 6076 cases of incident diverticular disease (diverticulosis and diverticulitis) among 385 291 participants and three studies with 1118 cases of complications related to diverticular disease (abscess or perforation) among 292 965. The summary RR for incident diverticular disease was 1.36 (95% CI 1.15-1.61, I = 84%, n = 4) for current smokers, 1.17 (95% CI 1.05-1.31, I = 49%, n = 4) for former smokers and 1.29 (95% CI 1.16-1.44, I = 62%, n = 5) for ever smokers. The summary RR was 1.11 (95% CI 0.99-1.25, I = 82%, n = 4) per 10 cigarettes per day. Although there was some indication of nonlinearity there was a dose-dependent positive association with increasing number of cigarettes smoked per day. There was some evidence that smoking also increases the risk of complications of diverticular disease, but the number of studies was small.
CONCLUSION
The current meta-analysis provides evidence that tobacco smoking is associated with an increased incidence of diverticular disease and related complications.
Topics: Adult; Aged; Aged, 80 and over; Diverticular Diseases; Diverticulitis; Diverticulum; Female; Humans; Incidence; Male; Middle Aged; Prospective Studies; Risk Factors; Tobacco Smoking
PubMed: 28556447
DOI: 10.1111/codi.13748 -
Diseases of the Colon and Rectum Jul 2023Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign disease is limited.
OBJECTIVE
This meta-analysis aimed to quantify the venous thromboembolism risk after benign colorectal resection and determine its variability.
DATA SOURCES
Following Preferred Reporting Items for Systematic Review and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology Guidelines (PROSPERO: CRD42021265438), Embase, MEDLINE, and 4 other registered medical literature databases were searched from the database inception to June 21, 2021.
STUDY SELECTION
Inclusion criteria: randomized controlled trials and large population-based database cohort studies reporting 30-day and 90-day venous thromboembolism rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: patients undergoing colorectal cancer or completely endoscopic surgery.
MAIN OUTCOME MEASURES
Thirty- and 90-day venous thromboembolism incidence rates per 1000 person-years after benign colorectal surgery.
RESULTS
Seventeen studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day venous thromboembolism incidence rates after benign colorectal resection were 284 (95% CI, 224-360) and 84 (95% CI, 33-218) per 1000 person-years. Stratified by admission type, 30-day venous thromboembolism incidence rates per 1000 person-years were 532 (95% CI, 447-664) for emergency resections and 213 (95% CI, 100-453) for elective colorectal resections. Thirty-day venous thromboembolism incidence rates per 1000 person-years after colectomy were 485 (95% CI, 411-573) for patients with ulcerative colitis, 228 (95% CI, 181-288) for patients with Crohn's disease, and 208 (95% CI, 152-288) for patients with diverticulitis.
LIMITATIONS
High degree of heterogeneity was observed within most meta-analyses attributable to large cohorts minimizing within-study variance.
CONCLUSIONS
Venous thromboembolism rates remain high up to 90 days after colectomy and vary by indication for surgery. Emergency resections compared to elective benign resections have higher rates of postoperative venous thromboembolism. Further studies reporting venous thromboembolism rates by type of benign disease need to stratify rates by admission type to more accurately define venous thromboembolism risk after colectomy.
REGISTRATION NO
CRD42021265438.
Topics: Humans; Adolescent; Adult; Venous Thromboembolism; Retrospective Studies; Colorectal Surgery; Risk Factors; Colectomy; Colorectal Neoplasms; Postoperative Complications
PubMed: 37134222
DOI: 10.1097/DCR.0000000000002915