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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 -
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 -
World Journal of Gastrointestinal... Mar 2021Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature.
BACKGROUND
Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature.
AIM
To systematically review all available evidence to describe the incidence, clinical course with management and propose a definition.
METHODS
The databases PubMed, EMBASE and Cochrane databases were searched using with the keywords up to June 2020. Additional manual search was performed and cross-checked for additional references. Data collected included demographics, reason for colonoscopy, time to diagnosis, method of diagnosis (clinical imaging) and management outcomes.
RESULTS
A total of nine studies were included in the final systematic review with a total of 339 cases. The time to diagnosis post-colonoscopy ranged from 2 h to 30 d. Clinical presentation for these patients were non-specific including abdominal pain, nausea/vomiting, per rectal bleeding and chills/fever. Majority of the cases were diagnosed based on computed tomography scan. The management for these patients were similar to the usual patients presenting with diverticulitis where most resolve with non-operative intervention (, antibiotics and bowel rest).
CONCLUSION
The entity of post-colonoscopy diverticulitis remains contentious where there is a wide duration post-procedure included. Regardless of whether this is a true complication post-colonoscopy or a event, early diagnosis is vital to guide appropriate treatment. Further prospective studies especially registries should include this as a complication to try to capture the true incidence.
PubMed: 33763188
DOI: 10.4253/wjge.v13.i3.82 -
European Journal of Gastroenterology &... Oct 2023The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of... (Meta-Analysis)
Meta-Analysis
The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.
Topics: Humans; Diverticulitis; Diverticulitis, Colonic; Anti-Infective Agents; Anti-Bacterial Agents
PubMed: 37577799
DOI: 10.1097/MEG.0000000000002622 -
Role of Dietary Habits in the Prevention of Diverticular Disease Complications: A Systematic Review.Nutrients Apr 2021Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the...
Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the effect of dietary habits in the prevention of diverticula complications (i.e., acute diverticulitis and diverticula bleeding) in patients with diverticula disease. PubMed and Scopus databases were searched up to 19 January 2021, 330 records were identified, and 8 articles met the eligibility criteria and were subjected to data extraction. The quality of the studies was evaluated by the Newcastle-Ottawa quality assessment form. No study meets the criteria for being a high-quality study. A high intake of fiber was associated to a decreased risk of diverticulitis or hospitalization due to diverticular disease, with a protective effect for fruits and cereal fiber, but not for vegetable fiber; whereas, a high red meat consumption and a generally Western dietary pattern were associated with an increased risk of diverticulitis. Alcohol use seemed to be associated to diverticular bleeding, but not to recurrent diverticulitis or diverticular complications. Further high-quality studies are needed to better define these associations. It is mandatory to ascertain the role of dietary habits for the development of recurrent acute diverticulitis and diverticular bleeding.
Topics: Diet, Western; Dietary Fiber; Diverticulitis; Diverticulosis, Colonic; Edible Grain; Feeding Behavior; Fruit; Gastrointestinal Hemorrhage; Hospitalization; Humans; Meat; Recurrence; Vegetables
PubMed: 33919755
DOI: 10.3390/nu13041288 -
RMD Open Sep 2022Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively...
A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases.
OBJECTIVES
Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases.
METHODS
A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration.
RESULTS
187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman's disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors.
CONCLUSION
IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
Topics: Adult; Humans; Antirheumatic Agents; Interleukin-6; Ligands; Receptors, Chimeric Antigen; COVID-19 Drug Treatment
PubMed: 36260501
DOI: 10.1136/rmdopen-2022-002359 -
Diseases of the Colon and Rectum Dec 2018The traditional approach for perforated diverticulitis, the Hartmann procedure, has considerable morbidity and the challenge of stoma reversal. Alternative procedures,... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The traditional approach for perforated diverticulitis, the Hartmann procedure, has considerable morbidity and the challenge of stoma reversal. Alternative procedures, including primary resection and anastomosis and laparoscopic lavage, have been proposed but remain controversial.
OBJECTIVE
The purpose of this study was to compare operative strategies for perforated diverticulitis.
DATA SOURCES
MEDLINE, Embase, Cochrane Library, and the grey literature were searched from inception to October 2017.
STUDY SELECTION
We included randomized clinical trials evaluating operative strategies for perforated diverticulitis.
INTERVENTIONS
Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage were included.
MAIN OUTCOME MEASURES
Data were independently extracted by 2 investigators. Risk of bias was evaluated using the Cochrane risk-of-bias tool. Pooled risk ratios for major complications, reoperation, and mortality were determined using random-effects models.
RESULTS
Six trials including 626 patients with perforated diverticulitis were identified. Laparoscopic lavage and sigmoidectomy had comparable rates of early reoperation and postoperative mortality; major complications (Clavien-Dindo >IIIa) were more frequent after laparoscopic lavage (RR = 1.68 (95% CI, 1.10-2.56); 3 trials, 305 patients). Comparing approaches for sigmoidectomy, primary resection and anastomosis had similar rates of major complications (RR = 0.88 (95% CI, 0.49-1.55); 3 trials, 255 patients) and postoperative mortality (RR = 0.58 (95% CI, 0.20-1.70); 3 trials, 254 patients) compared with the Hartmann procedure. However, patients who underwent primary resection and anastomosis were more likely to be stoma free at 12 months compared with the Hartmann procedure (RR = 1.40 (95% CI, 1.18-1.67); 4 trials, 283 patients) and to experience fewer major complications related to the stoma reversal procedure (RR = 0.26 (95% CI, 0.07-0.89); 4 trials, 186 patients).
LIMITATIONS
There were no limitations to this study.
CONCLUSIONS
Laparoscopic lavage is associated with increased risk of major complications versus primary resection for Hinchey III diverticulitis. The lower rate of stoma reversal and higher rate of complications after the Hartmann procedure suggest primary resection and anastomosis as the optimal management of perforated diverticulitis.
Topics: Anastomosis, Surgical; Colon, Sigmoid; Digestive System Surgical Procedures; Diverticulitis, Colonic; Humans; Intestinal Perforation; Laparoscopy; Postoperative Complications; Therapeutic Irrigation
PubMed: 30371549
DOI: 10.1097/DCR.0000000000001149 -
International Journal of Colorectal... Aug 2021Right-sided diverticulitis has different epidemiologic features compared to left-sided diverticulitis. However, data on the appropriate treatment of right-sided... (Meta-Analysis)
Meta-Analysis
PURPOSE
Right-sided diverticulitis has different epidemiologic features compared to left-sided diverticulitis. However, data on the appropriate treatment of right-sided diverticulitis are lacking. This systematic review aimed to examine the outcomes of conservative treatment for uncomplicated right-sided diverticulitis.
METHODS
MEDLINE, Embase, and the Cochrane Library were searched for articles published from January 1, 1990, to May 31, 2020. A total of 21 studies were included in the systematic review. We calculated proportions and 95% confidence intervals (CIs) to assess the outcomes of individual studies and pooled the results using a random effects model.
RESULTS
A total of 2811 patients (59.1% men; mean and median age, 37-54 years) with right-sided diverticulitis were included. The pooled rate of treatment failure was 2.5% (95% CI 1.2-4.3%; p <0.01; I = 64.0%). The recurrence rate ranged from 0 to 26.9%, and the pooled recurrence rate was 10.9% (95% CI 8.1-14.1%; p <0.01; I = 78.2%). The pooled rate of complicated diverticulitis at recurrence was 4.4% (95% CI 1.4-9.0%; p = 0.84; I = 0%). The pooled rate of emergency surgery at recurrence was 9.0% (95% CI 4.6-14.7%; p = 0.12; I = 30.3%).
CONCLUSIONS
Conservative treatment of uncomplicated right-sided diverticulitis results in a low rate of recurrence and complicated diverticulitis at recurrence. Based on these results, unnecessary surgery may be avoided and a new treatment paradigm for uncomplicated right-sided diverticulitis may be introduced.
Topics: Adult; Conservative Treatment; Diverticulitis; Diverticulitis, Colonic; Female; Humans; Male; Middle Aged; Recurrence; Treatment Outcome
PubMed: 33765173
DOI: 10.1007/s00384-021-03913-x -
International Journal of Colorectal... Mar 2018Diverticular disease is common and of increasing medical and economical importance. Various practice guidelines on diagnostic and treatment on this disease exist. We... (Comparative Study)
Comparative Study Meta-Analysis Review
PURPOSE
Diverticular disease is common and of increasing medical and economical importance. Various practice guidelines on diagnostic and treatment on this disease exist. We compared current guidelines on the disease in order to identify concordant and discordant recommendations.
METHOD
Eleven national and international guidelines on diverticular disease published over the last 10 years have been identified by a systematic literature review on PubMed and compared in detail for 20 main and 51 subtopics.
RESULTS
The available evidence for the most aspects was rated as moderate or low. There was concordance for the following items: Diagnosis of diverticulitis should be confirmed by imaging methods (10 of 10 guidelines). Mild forms may be treated out-patient (10/10). Abscesses are treated non-surgically (9/9). Elective surgery should be indicated by individual patient-related factors, only, and be performed laparoscopically (10/10, 9/9 respectively). Main differences were found in the questions of appropriate classification, imaging diagnostic (computed-tomography versus ultra-sound), need for antibiotics in out-patient treatment and mode of surgery for diverticular perforation. Despite growing evidence that antibiotics are not needed for treating mild diverticulitis, only 3/10 guidelines have corresponding recommendations. Hartmann's procedure has been abandoned several years ago and is now recommended for feculent peritonitis by the three most recent guidelines. In contrast, laparoscopic lavage without resection is not recommended anymore.
CONCLUSION
There are dissents in the recommendations for central aspects regarding the diagnostic and treatment of diverticular disease in recently published guidelines.
Topics: Diverticular Diseases; Humans; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 29349481
DOI: 10.1007/s00384-017-2960-z -
Digestive Surgery 2017The study aimed to perform a meta-analysis comparing laparoscopic and open surgery for diverticulitis. (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND/AIMS
The study aimed to perform a meta-analysis comparing laparoscopic and open surgery for diverticulitis.
METHODS
Studies comparing the outcomes of laparoscopic surgery versus open surgery for diverticulitis that reported quantitative data were included. Outcome measures were mortality and morbidity rates and length of hospital stay.
RESULTS
Four randomized controlled trials - 3 prospective and 21 retrospective - were included in the analysis. The total numbers of patients ranged from 5 to 14,562 in the laparoscopic groups and from 4 to 110,172 in the open surgery groups, and the mean patient age ranged from 38.9 to 78 years. Overall analysis revealed that laparoscopic surgery was associated with lower mortality (pooled OR 0.40, 95% CI 0.25-0.63, p < 0.001) and a lower overall morbidity rate (pooled OR 0.65, 95% CI 0.51-0.82, p < 0.001) than open surgery. Laparoscopic surgery was associated with a higher anastomotic bleeding rate, but lower rates of ileus, anastomotic leakage, small bowel obstruction, wound infection, fascial dehiscence and intra-abdominal abscesses. Length of hospital stay was less with laparoscopic surgery.
CONCLUSIONS
The current meta-analysis supports the use of laparoscopy for the treatment of diverticulitis. The results, however, should be interpreted with caution.
Topics: Abdominal Abscess; Anastomosis, Surgical; Anastomotic Leak; Colectomy; Colon; Diverticulitis, Colonic; Humans; Ileus; Laparoscopy; Length of Stay; Postoperative Complications; Surgical Wound Dehiscence; Surgical Wound Infection
PubMed: 27941315
DOI: 10.1159/000450683