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ANZ Journal of Surgery May 2023Traditionally, international guidelines recommend patients with acute diverticulitis should be followed up with a colonoscopy 6-8 weeks after discharge. However, the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Traditionally, international guidelines recommend patients with acute diverticulitis should be followed up with a colonoscopy 6-8 weeks after discharge. However, the need for an interval colonoscopy has been increasingly challenged in the setting of computed tomography (CT). Previous meta-analyses have included studies which combined suspected rather than imaging confirmed diverticulitis and often without correlation with endoscopic findings. This meta-analysis aims to investigate endoscopic findings of patients with CT confirmed diverticulitis.
METHODS
An electronic search of Medline, PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, Clinicaltrials.gov and WHO ICTRP was performed up to October 18, 2021. Studies which reported CT confirmed acute diverticulitis in adults and who underwent endoscopic follow-up with either a colonoscopy or flexible sigmoidoscopy were included. Studies were excluded if diverticulitis was diagnosed by clinical grounds alone, ultrasound, barium enema, or other non-CT forms of imaging.
RESULTS
A total of 68 studies with 13 905 patients were included. Median age was 58 years and male to female ratio was 0.84. Cancer was detected in 2.0% and advanced adenoma in 3.8%. Complicated diverticulitis had 9.2 higher odds of cancer compared to uncomplicated diverticulitis (95% CI 4.42-19.08, P < 0.001). Adenomas were detected in 17%. Of those diagnosed with colorectal cancer, 85% were concordant with the site of the diverticulitis on CT while 15% were incidental findings.
CONCLUSION
Routine colonoscopic follow up should be recommended in medically fit patients who have CT proven acute diverticulitis due to the higher than population prevalence of colorectal cancer and advanced adenomas.
Topics: Adult; Humans; Male; Female; Middle Aged; Diverticulitis, Colonic; Diverticulitis; Colorectal Neoplasms; Colonoscopy; Acute Disease; Adenoma; Retrospective Studies
PubMed: 36529882
DOI: 10.1111/ans.18190 -
European Journal of Trauma and... Oct 2023The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36%...
BACKGROUND
The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease.
AIM
To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis.
METHODS
This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis.
RESULTS
We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05).
CONCLUSIONS
Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.
Topics: Male; Female; Humans; Adult; Middle Aged; Aged; Diverticulitis, Colonic; Conservative Treatment; Treatment Outcome; Retrospective Studies; Diverticulitis
PubMed: 35262746
DOI: 10.1007/s00068-022-01922-1 -
The American Surgeon Dec 2023The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of...
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
Topics: Humans; United States; Retrospective Studies; Washington; Diverticulitis; Hospitalization; Patient Acuity
PubMed: 37144833
DOI: 10.1177/00031348231174002 -
Der Chirurg; Zeitschrift Fur Alle... Aug 2021The correct medical indications are the fundamental decision process for the surgical treatment and ensuring the quality. (Review)
Review
BACKGROUND
The correct medical indications are the fundamental decision process for the surgical treatment and ensuring the quality.
OBJECTIVE
Description of the indications for surgical treatment of the various types of diverticular disease according to the current level of evidence.
MATERIAL AND METHODS
The narrative review is based on current national and international guidelines and a selective literature search.
RESULTS
There are basically three main indications for resection of the sigmoid colon. 1) Prophylactic for avoidance of complications after successful conservative treatment of acute complicated diverticulitis with macroabscess formation and high risk of recurrence (classification of diverticular disease, CDD, type 2b). 2) In patients with persistent symptoms and impaired quality of life resection of the sigmoid colon of various types (CDD types 1-3) can effectively enable a significant improvement in the quality of life and is therefore to be recommended in cases of individually acceptable perioperative risks. 3) Indications for urgent resection of the sigmoid colon are present for free perforation or failure of conservative treatment.
CONCLUSION
The indications for surgery should be defined by the type of diverticular disease, the aim of surgical treatment, the evaluation of the efficacy of surgical treatment in comparison to conservative treatment and an individual appraisal of the risks.
Topics: Colon, Sigmoid; Diverticular Diseases; Diverticulitis; Diverticulitis, Colonic; Humans; Quality of Life; Recurrence
PubMed: 34100113
DOI: 10.1007/s00104-021-01432-7 -
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 -
International Journal of Colorectal... Aug 2020Large bowel obstruction and megacolon formation secondary to complicated diverticulitis is rare.
PURPOSE
Large bowel obstruction and megacolon formation secondary to complicated diverticulitis is rare.
METHODS
We present a case of an 84-year-old woman surviving large bowel obstruction and mega-megacolon formation secondary to complicated diverticulitis, with an impressive presentation of abdominal distention.
RESULTS
The patient's symptoms, laboratory test results, and imaging were consistent with large bowel obstruction. The patient underwent urgent exploratory laparotomy. Upon entry in the abdomen, it was unexpected that the extreme colonic wall thickening had prevented perforation, indicating the longtime course of illness. The biopsy of the specimen from the site of the obstruction demonstrated an inflammatory obstructing mass.
CONCLUSION
This report aims to point out the atypical and in-extremes presentation of an otherwise common disease.
Topics: Aged, 80 and over; Diverticulitis; Female; Humans; Intestinal Obstruction; Laparotomy; Megacolon
PubMed: 32447480
DOI: 10.1007/s00384-020-03642-7 -
Annals of Internal Medicine Mar 2022The value of interventions used after acute colonic diverticulitis is unclear.
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).
Topics: Colonoscopy; Diverticulitis; Diverticulitis, Colonic; Humans; Mesalamine; United States
PubMed: 35038269
DOI: 10.7326/M21-1646 -
Medicina (Kaunas, Lithuania) Oct 2021: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of... (Review)
Review
: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. : We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. : We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. : During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.
Topics: Acute Disease; COVID-19; Diverticulitis; Diverticulitis, Colonic; Humans; Pandemics; SARS-CoV-2
PubMed: 34684164
DOI: 10.3390/medicina57101127 -
Khirurgiia 2021The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center... (Review)
Review
The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.
Topics: Diverticulitis; Humans; Randomized Controlled Trials as Topic; Retrospective Studies; Secondary Prevention
PubMed: 33710833
DOI: 10.17116/hirurgia202103183 -
International Journal of Surgery... May 2023Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned.
OBJECTIVE
The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD.
DATA SOURCES
PubMed, Medline, Embase, Web of Science, and the Cochrane Library.
METHODS
A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis.
STUDY SELECTION
RCTs on treating AUD without antibiotics published in English before December 2022 were included.
INTERVENTION
Treatments without antibiotics were compared with treatments with antibiotics.
MAIN OUTCOME MEASURES
The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis.
RESULTS
The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR)=1.39; 95% CI: 0.93-2.06; P =0.11; I2 =0%], change in strategy (OR=1.03; 95% CI: 0.52-2,02; P =0.94; I2 =44%), emergency surgery (OR=0.43; 95% CI: 0.12-1.53; P =0.19; I2 =0%), worsening (OR=0.91; 95% CI: 0.48-1.73; P =0.78; I2 =0%), and persistent diverticulitis (OR=1.54; 95% CI: 0.63-3.26; P =0.26; I2 =0%).
LIMITATIONS
Heterogeneity and a limited number of RCTs.
CONCLUSIONS
Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings.
Topics: Humans; Acute Disease; Randomized Controlled Trials as Topic; Diverticulitis; Anti-Bacterial Agents
PubMed: 37026842
DOI: 10.1097/JS9.0000000000000307