-
Clinical Gastroenterology and... Mar 2022
Topics: Defecation; Diverticulitis; Humans
PubMed: 33716142
DOI: 10.1016/j.cgh.2021.03.012 -
Surgical Endoscopy Aug 2023We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal...
INTRODUCTION
We implemented the NICE procedure as a robotic natural orifice colorectal resection utilizing the rectum to extract the specimen and complete an intracorporal anastomosis for diverticulitis in 2018. Although complicated diverticulitis is associated with higher rates of conversion and post-operative morbidity, we hypothesized that the stepwise approach of the NICE procedure can be equally successful in this cohort. We aimed to compare feasibility and outcomes of the NICE procedure for uncomplicated and complicated diverticulitis.
METHODS
Consecutive patients presenting with diverticulitis who underwent robotic NICE procedure from May 2018 through June 2021 were included. Cases were stratified into uncomplicated and complicated diverticulitis (fistula, abscess, or stricture). Demographic, clinical, disease, intervention, and outcomes data were analyzed. The main outcome measures were return of bowel function, length of stay, opioid consumption, and postoperative complications.
RESULTS
Of a total of 190 patients, those presenting with uncomplicated diverticulitis (53.2%) were compared to those with complicated diverticulitis (47.8%). Uncomplicated diverticulitis had fewer low anterior resections (15.8% vs 49.4%; p < 0.001) and shorter median operative time (186 vs 220 min; p < 0.001). Both cohorts had equal rates of successful intracorporeal anastomosis (100%) and successful transrectal extraction (100% vs 98.9%; p = 0.285). Both cohorts had similar return of bowel function (median 21 h and 18.5; p = 0.149), median length of hospital stay (2 days, p = 0.015) and mean total opioid use (68.4 MME vs 67.3; p = 0.91). There were also no significant differences in overall postoperative complication rate over a 30-day time period (8.9% vs 12.5%; p = 0.44), readmission (6.9% vs 5.6%; p = 0.578) and reoperation (3% vs 4.5%; p = 0.578).
CONCLUSION
Despite being inherently more complex and technically challenging, complicated diverticulitis patients have similar success rates and post-operative outcomes compared to uncomplicated diverticulitis patients when undergoing the NICE procedure. These results implicate the benefits of robotic natural orifice techniques may be even more pronounced in complicated diverticulitis patients.
Topics: Humans; Robotic Surgical Procedures; Analgesics, Opioid; Laparoscopy; Diverticulitis; Robotics; Colectomy; Postoperative Complications; Treatment Outcome; Diverticulitis, Colonic; Retrospective Studies
PubMed: 37002495
DOI: 10.1007/s00464-023-09973-0 -
Colorectal Disease : the Official... Jun 2023Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent....
AIM
Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients.
METHOD
This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management.
RESULTS
Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p = 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79-16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p = 0.84) and failure of nonoperative management (7% vs. 9%, p = 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy.
CONCLUSION
Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.
Topics: Humans; Diverticulitis, Colonic; Cohort Studies; Retrospective Studies; Treatment Outcome; Diverticulitis; Organ Transplantation; Postoperative Complications; Colectomy
PubMed: 36945080
DOI: 10.1111/codi.16544 -
Medicina (Kaunas, Lithuania) Dec 2021: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate...
: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. : This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo). : We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients ( < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage ( = 0.006). : The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.
Topics: Aged; Aged, 80 and over; Conservative Treatment; Diverticulitis; Diverticulitis, Colonic; Female; Humans; Male; Retrospective Studies
PubMed: 35056340
DOI: 10.3390/medicina58010029 -
Colorectal Disease : the Official... Apr 2023Several papers have been published about the risk of recurrence after an attack of diverticulitis treated conservatively. However, very few papers have been devoted to...
AIM
Several papers have been published about the risk of recurrence after an attack of diverticulitis treated conservatively. However, very few papers have been devoted to the risk of postoperative recurrence of diverticulitis (PRD) after prophylactic sigmoidectomy (PS). The aim of this work was to report the rate of PRD after PS and to assess possible risk factors for recurrence after surgery.
METHOD
All consecutive patients who underwent elective laparoscopic PS for diverticulitis between 2005 and 2019 were retrospectively included. PRD was assessed.
RESULTS
Three hundred and sixty four patients (199 men, mean age 54 ± 13 years) were included. Among these, 26 (7%) presented with 1.7 ± 1 (range 1-4) episodes of recurrence of diverticulitis after a mean delay of 44 ± 39 months (1 month-11 years) after surgery. Patients who presented with postoperative recurrence of diverticulitis were younger (46 ± 11 vs. 55 ± 13 years, p = 0.002) and more frequently had uncomplicated diverticulitis [15/26 (58%) vs. 97/338 (29%), p = 0.002] and more than two previous episodes before PS [17/26 (65%) vs. 132/338 (39%), p = 0.009] than patients without PRD. After multivariate analysis, two independent risk factors for PRD were identified: patients with more than two episodes before PS (OR = 3.3, 95% CI = 1.2-9, p = 0.005) and age < 50 years (OR = 4.5, 95% CI = 2-11, p = 0.001). If both factors were present, recurrence reached 18% (9/51).
CONCLUSION
Postoperative recurrence of diverticulitis is rare (7%) after PS for diverticulitis. Some patients (i.e. those with more than two episodes before PS and/or age <50 years) could be exposed to a higher risk of recurrence (up to 18%), making prophylactic surgery questionable in these patients.
Topics: Male; Humans; Adult; Middle Aged; Aged; Retrospective Studies; Laparoscopy; Recurrence; Diverticulitis; Colon, Sigmoid; Elective Surgical Procedures; Diverticulitis, Colonic
PubMed: 36464948
DOI: 10.1111/codi.16426 -
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 -
International Journal of Colorectal... Feb 2021Acute diverticulitis is the third most frequent cause of gastrointestinal admission in the USA. We sought to determine the incidence of recurrence within a 90-day period...
OBJECTIVES
Acute diverticulitis is the third most frequent cause of gastrointestinal admission in the USA. We sought to determine the incidence of recurrence within a 90-day period and determine its impact on mortality and hospital utilization.
METHODS
Nationwide Readmission Database (NRD) 2016 was used to identify patients ≥ 18 years old with a principal diagnosis of acute diverticulitis who were readmitted for recurrence within 90 days. The primary outcome was 90-day readmission rate for acute diverticulitis, and predictors were analyzed using a multivariate regression analysis. Secondary outcomes were mortality and hospital resource utilization.
RESULTS
A total of 171,238 admissions were included which met inclusion criteria. Ninety-day readmission for acute diverticulitis after index diverticulitis hospitalization was 8.9%. Readmissions were associated with in-hospital additional total cost of $444,726,560 and 65,685 total hospital days and mortality rate of 4.69% compared with mortality rate of 5.20% on index hospitalization (p < 0.01). In multivariable analysis, increased odds of readmission were associated with disposition against medical advice (OR 1.75, 95% CI 1.31-2.33), younger age (OR 0.98, 95% CI 0.98-0.99), and shorter length of stay (OR 0.99, CI 0.98-0.99).
CONCLUSIONS
Acute diverticulitis is frequently associated with recurrence within 90 days and bears a substantial financial and mortality burden. Targeted interventions are needed to minimize readmissions in identified subpopulations.
Topics: Adolescent; Diverticulitis; Hospitalization; Humans; Incidence; Neoplasm Recurrence, Local; Patient Readmission; Retrospective Studies; Risk Factors; United States
PubMed: 33025103
DOI: 10.1007/s00384-020-03769-7 -
Surgery Apr 2023Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out...
BACKGROUND
Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out of fear of high permanent stoma rate. The aim of this study was to investigate the rate of stoma reversal, reasons behind nonreversal, and safety of reversal surgery.
METHODS
This was a single-center retrospective study of patients undergoing urgent Hartmann's procedure due to acute diverticulitis between the years 2006 and 2017 with follow-up until March 2021.
RESULTS
A total of 3,319 episodes of diverticulitis in 2,932 patients were screened. The Hartmann's procedure was performed on 218 patients, of whom 157 (72%) had peritonitis (48 (22%) with organ dysfunction). At 2-years, 76 (34.9%) patients had died with stoma, 42 (19.3%) were alive with stoma, and 100 (45.9%) had undergone stoma reversal. The survival of patients with and without reversal were 100% and 42.7% at 1-year, 96.0% and 35.0% at 2-years and 88.9% and 20.7% at 5-years, respectively. The risk factors for nonreversal were old age, a need for outside assistance, low HElsinki Staging for Acute Diverticulitis stage, and higher C-reactive protein level upon hospital admission. The most common reasons for nonreversal in surviving patients were patient not willing to have the operation 18 (41%) and dementia 10 (23%). Twelve (12%) patients had a major complication after reversal (Clavien-Dindo IIIb-IV) and 90-day mortality after reversal was 0%.
CONCLUSION
After the Hartmann's procedure for acute diverticulitis, one-third died, half underwent stoma reversal, and one-fifth did not undergo stoma reversal within 2 years. Patients who survive with stoma are either not willing to have reversal or have severe comorbidities excluding elective surgery. The Hartmann's procedure remains a viable option for high-risk patients with perforated acute diverticulitis.
Topics: Humans; Retrospective Studies; Multiple Organ Failure; Diverticulitis; Colostomy; Surgical Stomas
PubMed: 36517294
DOI: 10.1016/j.surg.2022.10.028 -
Inflammatory Bowel Diseases Jun 2021There has been a historic similarity in the epidemiology and pathophysiology of diverticular disease and inflammatory bowel disease (IBD). Because there are limited to...
BACKGROUND
There has been a historic similarity in the epidemiology and pathophysiology of diverticular disease and inflammatory bowel disease (IBD). Because there are limited to no data on the role of diverticulitis as a potential risk factor for de novo IBD, we aimed to evaluate the role of diverticulitis and complicated diverticulitis as a potential predictor of IBD.
METHODS
We performed a retrospective, single-center study including patients older than age 18 years who were diagnosed with diverticulitis from January 2012 until December 2018 without a prior diagnosis of IBD. These patients were then evaluated for development of IBD. Univariate and multivariate analyses were conducted to compare the characteristics and outcomes between patients who did or did not develop IBD.
RESULTS
A total of 2770 patients were diagnosed with diverticulitis from 2012 until 2018. Of these patients, 17 were diagnosed with IBD, resulting in an incidence rate of 0.23% per patient-year. The incidence rate among patients who required surgery for diverticulitis was 0.44% per patient-year, and patients with complicated diverticulitis had an incidence rate of 0.91% per patient-year. Univariate analysis showed that the need for surgery related to diverticulitis (hazard ratio [HR], 6.27; P = 0.003) and complicated diverticulitis was associated with the development of IBD (HR, 14.71; P < 0.001). Multivariate analysis showed that complicated diverticulitis was the sole factor associated with IBD (HR, 10.34; P < 0.001).
CONCLUSIONS
Patients with diverticulitis are at a higher risk of developing de novo IBD. This risk is highest in patients with complicated diverticulitis.
Topics: Diverticulitis; Humans; Incidence; Inflammatory Bowel Diseases; Retrospective Studies; Risk Factors
PubMed: 33237324
DOI: 10.1093/ibd/izaa299 -
Minerva Surgery Aug 2023Acute left colonic diverticulitis (ALCD) is a common clinical condition encountered by physicians in the emergency setting. Clinical presentation of ALCD ranges from... (Review)
Review
Acute left colonic diverticulitis (ALCD) is a common clinical condition encountered by physicians in the emergency setting. Clinical presentation of ALCD ranges from uncomplicated acute diverticulitis to diffuse fecal peritonitis. ALCD may be diagnosed based on clinical features alone, but imaging is necessary to differentiate uncomplicated from complicated forms. In fact, computed tomography scan of the abdomen and pelvis is the highest accurate radiological examination for diagnosing ALCD. Treatment depends on the clinical picture, the severity of patient's clinical condition and underlying comorbidities. Over the last few years, diagnosis and treatment algorithms have been debated and are currently evolving. The aim of this narrative review was to consider the main aspects of diagnosis and treatment of ALCD.
Topics: Humans; Diverticulitis, Colonic; Diverticulitis; Radiography; Tomography, X-Ray Computed
PubMed: 37021824
DOI: 10.23736/S2724-5691.23.09857-X