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International Journal of Colorectal... Apr 2007To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with... (Comparative Study)
Comparative Study Review
OBJECTIVE
To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with acute complicated sigmoid diverticulitis.
SEARCH STRATEGY
MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann's procedure. The term "diverticulitis, colonic" with the sub-heading "surgery" was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: "surgical procedures, operative", "surgical anastomosis", and "Hartmann procedure", combined with the term "diverticulitis, colonic". The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied.
RESULTS
Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann's procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann's procedure.
CONCLUSIONS
This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of peri-operative complications. The need for revision of Hartmann's procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias.
Topics: Acute Disease; Anastomosis, Surgical; Clinical Trials as Topic; Diverticulitis, Colonic; Humans; Intraoperative Complications; MEDLINE
PubMed: 16437211
DOI: 10.1007/s00384-005-0059-4 -
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 -
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 -
Journal of Gastroenterology and... Aug 2013For years, the natural course of diverticulitis in the young has been debatable in terms of its severity and recurrence rate, and no consensus has been reached regarding... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIM
For years, the natural course of diverticulitis in the young has been debatable in terms of its severity and recurrence rate, and no consensus has been reached regarding its treatment and timing of surgery. Thus, the study aims to evaluate by meta-analysis the natural course of acute diverticulitis in the young.
METHODS
Data were obtained from electronic databases and manual search of studies comparing the course of diverticulitis in young versus elderly patients. The age cut-off was selected to be 40-50 years, and only studies using computed tomography as the sole modality for diagnosis were included. Primary outcomes were surgery during hospitalization and disease recurrence. Relative risks (RRs) with 95% confidence intervals (CIs) are reported.
RESULTS
One thousand eighty publications were found, 12 of which were included. The total number of patients was 4982. Most young patients were males (RR 1.70, 95% CI 1.31-2.21), without tendency toward a more complicated disease at admission (RR 0.95, 95% CI 0.46-1.97). While there was no significant difference in the rate of surgery during hospitalization (RR 0.69, 95% CI 0.46-1.06), young patients underwent more elective surgeries (RR 2.39, 95% CI 1.82-3.15). No mortality was recorded among young patients. The disease recurrence rate was significantly higher than that of elderly patients (RR 1.70, 95% CI 1.31-2.21); however, no study specified the mean follow-up period for each group.
CONCLUSIONS
The course of diverticulitis in the young is not more severe than that in elderly patients; however, the disease tends to recur more often. Therefore, while choosing a therapeutic regimen, factors other than age should also be considered.
Topics: Acute Disease; Adult; Age Factors; Aged; Diverticulitis; Female; Follow-Up Studies; Hospitalization; Humans; MEDLINE; Male; Middle Aged; Prognosis; Recurrence; Risk; Severity of Illness Index; Sex Factors; Tomography, X-Ray Computed
PubMed: 23701446
DOI: 10.1111/jgh.12274 -
Annals of Surgery Feb 2014To determine the yield of colorectal cancer at routine colonic evaluation after radiologically proven acute diverticulitis. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To determine the yield of colorectal cancer at routine colonic evaluation after radiologically proven acute diverticulitis.
BACKGROUND
Acute diverticulitis accounts for 152,000 hospitalizations in the United States alone. Current guidelines recommend routine colonic evaluation after acute diverticulitis to confirm the diagnosis and exclude malignancy. However, research suggests that the yield of colorectal cancer after computed tomography-proven uncomplicated diverticulitis may be low. In the era of widespread computed tomographic scanning for diverticulitis, routine colonic evaluation after diverticulitis may represent a nonessential burden on health care resources.
METHODS
The PubMed (MEDLINE), EMBASE, BIREME, CINAHL, and the Cochrane Library databases were searched. Original studies of colonic evaluation after proven acute diverticulitis were included. Meta-analysis of data from included studies was performed using a DerSimonian Laird random effect proportion analysis.
RESULTS
Eleven studies from 7 countries were included in the analysis. Out of a pooled population of 1970 patients, cancer was found in 22. The pooled proportional estimate of malignancy was 1.6% (95% confidence interval [CI], 0.9%-2.8%). Of the 1497 patients with uncomplicated diverticulitis, cancer was found in 5 (proportional estimate of risk 0.7%; CI, 0.3%-1.4%). Of the 79 patients with complicated disease, cancer was found in 6 (proportion estimate of risk 10.8%; CI, 5.2%-21.0%).
CONCLUSIONS
The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, routine colonoscopy may not be necessary. Patients with complicated diverticulitis still have a significant risk of colorectal cancer at subsequent colonic evaluation.
Topics: Acute Disease; Colonoscopy; Colorectal Neoplasms; Diverticulitis, Colonic; Humans; Intestinal Polyps; Risk Assessment; Tomography, X-Ray Computed
PubMed: 24169174
DOI: 10.1097/SLA.0000000000000294 -
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 -
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 -
Colorectal Disease : the Official... Jan 2018Acute uncomplicated diverticulitis (AUD) is common and antibiotics are the cornerstone of traditional conservative management. This approach lacks clear evidence base... (Review)
Review
BACKGROUND
Acute uncomplicated diverticulitis (AUD) is common and antibiotics are the cornerstone of traditional conservative management. This approach lacks clear evidence base and studies have recently suggested that avoidance of antibiotics is a safe and efficacious way to manage AUD. The aim of this systematic review is to determine the safety and efficacy of treating AUD without antibiotics.
METHODS
A systematic search of Embase, Cochrane library, MEDLINE, Science Citation Index Expanded, and ClinicalTrials. gov was performed. Studies comparing antibiotics versus no antibiotics in the treatment of AUD were included. Meta-analysis was performed using the random effects model with the primary outcome measure being diverticulitis-associated complications. Secondary outcomes were readmission rate, diverticulitis recurrence, mean hospital stay, requirement for surgery and requirement for percutaneous drainage.
RESULTS
Eight studies were included involving 2469 patients; 1626 in the non-antibiotic group (NAb) and 843 in the antibiotic group (Ab). There was a higher complication rate in the Ab group however this was not significant (1.9% versus 2.6%) with a combined risk ratio (RR) of 0.63 (95% CI, 0.25 to 1.57, p=0.32). There was a shorter mean length of hospital stay in the Nab group (standard mean difference of -1.18 (95% CI, -2.34 to -0.03 p= 0.04). There was no significant difference in readmission, recurrence and surgical intervention rate or requirement for percutaneous drainage.
CONCLUSION
Treatment of AUD without antibiotics may be feasible with outcomes that are comparable to antibiotic treatment and with potential benefits for patients and the NHS. Large scale randomised multicentre studies are needed. This article is protected by copyright. All rights reserved.
PubMed: 29323778
DOI: 10.1111/codi.14013 -
Nutrients Jan 2018In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review... (Review)
Review
In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review the evidence and develop recommendations for dietary fibre modifications, either alone or alongside probiotics or antibiotics, versus any comparator in adults in any setting with or recently recovered from acute, uncomplicated diverticulitis. Intervention and observational studies in any language were located using four databases until March 2017. The Cochrane Risk of Bias tool and GRADE were used to evaluate the overall quality of the evidence and to develop recommendations. Eight studies were included. There was "very low" quality evidence for comparing a liberalised and restricted fibre diet for inpatient management to improve hospital length of stay, recovery, gastrointestinal symptoms and reoccurrence. There was "very low" quality of evidence for using a high dietary fibre diet as opposed to a standard or low dietary fibre diet following resolution of an acute episode, to improve reoccurrence and gastrointestinal symptoms. The results of this systematic review and GRADE assessment conditionally recommend the use of liberalised diets as opposed to dietary restrictions for adults with acute, uncomplicated diverticulitis. It also strongly recommends a high dietary fibre diet aligning with dietary guidelines, with or without dietary fibre supplementation, after the acute episode has resolved.
Topics: Acute Disease; Anti-Bacterial Agents; Diet; Dietary Fiber; Diverticulitis; Evidence-Based Medicine; Humans; Meta-Analysis as Topic; Observational Studies as Topic; Probiotics; Randomized Controlled Trials as Topic; Recurrence; Risk Factors
PubMed: 29382074
DOI: 10.3390/nu10020137 -
JAMA Surgery Mar 2014Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years. (Review)
Review
IMPORTANCE
Diverticulitis of the sigmoid colon is an increasingly common disease. Patterns of care and management guidelines have significantly evolved in recent years.
OBJECTIVES
To review and classify the primary data published since 2000 that are guiding decision making, technical considerations, and the outcomes of surgery for sigmoid diverticulitis.
EVIDENCE REVIEW
We searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for studies pertaining to the diagnosis and management of chronic and recurrent diverticulitis from January 1, 2000, to March 31, 2013. We supplemented this automated search with references drawn from included studies and PubMed. We rated the level of evidence according to American College of Cardiology/American Heart Association guidelines.
FINDINGS
We identified 68 studies meeting inclusion criteria for final review. The studies were almost exclusively observational and had limited certainty of treatment effect. We found that complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%) and that age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications. Chronic symptoms may persist even after resection in 5% to 22% of patients. Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease. Decisions to proceed with colon resection should be based instead on the patient-reported frequency and severity of diverticulitis symptoms.
CONCLUSIONS AND RELEVANCE
The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted. Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk. Laparoscopic surgery is preferred to open approaches. Recent evidence suggests that existing guidelines should be updated.
Topics: Chronic Disease; Colectomy; Diverticulitis, Colonic; Elective Surgical Procedures; Evidence-Based Medicine; Humans; Practice Patterns, Physicians'; Recurrence; Sigmoid Diseases; Tomography, X-Ray Computed
PubMed: 24430164
DOI: 10.1001/jamasurg.2013.5477