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Diseases of the Colon and Rectum Dec 2014Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous... (Review)
Review
BACKGROUND
Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous drainage followed by delayed resection. Controversy has arisen regarding the necessity of elective surgery, when nonoperative management has successfully resolved the index attack.
OBJECTIVE
The aim of this systematic review was to analyze the literature to determine the recurrence rate in those patients who were successfully managed nonoperatively and determine the role of elective surgical resection.
DATA SOURCES
An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews performed from 1986 to 2014. The search terms used were as follows: "diverticulitis," "abscess," "diverticular abscess," "percutaneous drainage," and "surgery."
STUDY SELECTION
Studies included for review evaluated the management of diverticular abscesses and the subsequent role of delayed elective resection.
INTERVENTIONS
All of the studies were systematically reviewed and underwent a meta-analysis.
MAIN OUTCOME MEASURES
End points were the need for surgery and recurrent attacks without surgery.
RESULTS
Twenty-two studies reporting a total of 1051 patients with acute diverticulitis with abscess formation (modified Hinchey grades IB and II) were included in the review. Percutaneous drainage was successful in 49% patients (diameter, >3 cm) and antibiotic therapy in 14% patients. Urgent surgery during the index hospitalization was performed in 30% of patients, elective resection in 36%, and no surgery in 35%. Recurrence rates were high, with 39% in patients awaiting elective resection and 18% in the nonsurgery group, with an overall recurrence rate of 28%. Of the whole cohort, only 28% had no surgery and no recurrence during follow-up.
LIMITATIONS
Sample size, heterogeneity, selection and treatment bias, and limited follow-up of included studies were limitations to this study.
CONCLUSIONS
The evidence from the literature is weak but still suggests that complicated diverticulitis with abscess formation is associated with a high probability of resective surgery, whereas conservative management may result in chronic or recurrent diverticular symptoms.
Topics: Abdominal Abscess; Anti-Bacterial Agents; Colectomy; Disease Management; Diverticulitis, Colonic; Drainage; Elective Surgical Procedures; Humans; Outcome Assessment, Health Care; Recurrence; Time-to-Treatment
PubMed: 25380010
DOI: 10.1097/DCR.0000000000000230 -
Frontiers in Robotics and AI 2023Complicated diverticulitis is a common abdominal emergency that often requires a surgical intervention. The systematic review and meta-analysis below compare the...
Complicated diverticulitis is a common abdominal emergency that often requires a surgical intervention. The systematic review and meta-analysis below compare the benefits and harms of robotic vs. laparoscopic surgery in patients with complicated colonic diverticular disease. The following databases were searched before 1 March 2023: Cochrane Library, PubMed, Embase, CINAHL, and ClinicalTrials.gov. The internal validity of the selected non-randomized studies was assessed using the ROBINS-I tool. The meta-analysis and trial sequential analysis were performed using RevMan 5.4 (Cochrane Collaboration, London, United Kingdom) and Copenhagen Trial Unit Trial Sequential Analysis (TSA) software (Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark), respectively. We found no relevant randomized controlled trials in the searched databases. Therefore, we analyzed 5 non-randomized studies with satisfactory internal validity and similar designs comprising a total of 442 patients (184 (41.6%) robotic and 258 (58.4%) laparoscopic interventions). The analysis revealed that robotic surgery for complicated diverticulitis (CD) took longer than laparoscopy (MD = 42 min; 95% CI: [-16, 101]). No statistically significant differences were detected between the groups regarding intraoperative blood loss (MD = -9 mL; 95% CI: [-26, 8]) and the rate of conversion to open surgery (2.17% or 4/184 for robotic surgery vs. 6.59% or 17/258 for laparoscopy; RR = 0.63; 95% CI: [0.10, 4.00]). The type of surgery did not affect the length of in-hospital stay (MD = 0.18; 95% CI: [-0.60, 0.97]) or the rate of postoperative complications (14.1% or 26/184 for robotic surgery vs. 19.8% or 51/258 for laparoscopy; RR = 0.81; 95% CI: [0.52, 1.26]). No deaths were reported in either group. The meta-analysis suggests that robotic surgery is an appropriate option for managing complicated diverticulitis. It is associated with a trend toward a lower rate of conversion to open surgery and fewer postoperative complications; however, this trend does not reach the level of statistical significance. Since no high quality RCTs were available, this meta-analysis isnot able to provide reliable conclusion, but only a remarkable lack of proper evidence supporting robotic technology. The need for further evidence-based trials is important.
PubMed: 37779579
DOI: 10.3389/frobt.2023.1208611 -
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 -
International Journal of Colorectal... Jul 2014Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an... (Review)
Review
PURPOSE OF REVIEW
Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach.
METHODS
Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion.
RESULTS
Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %.
CONCLUSION
Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.
Topics: Acute Disease; Ambulatory Care; Anti-Bacterial Agents; Diverticulitis; Fluid Therapy; Humans; Infusions, Intravenous; Severity of Illness Index
PubMed: 24859874
DOI: 10.1007/s00384-014-1900-4 -
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 -
Langenbeck's Archives of Surgery Feb 2018The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis. (Review)
Review
BACKGROUND
The objective of this article is to review the evolving role of laparoscopic surgery in the treatment of complicated diverticulitis.
PURPOSE
The authors attempted to give readers a concise insight into the evidence available in the English language literature. This study does not offer a systematic review of the topic, rather it highlights the role of laparoscopy in the treatment of complicated diverticulitis.
CONCLUSIONS
New level 1 evidence suggest that observation rather than elective resection following nonoperative management of diverticulitis with abscess and/or extraluminal air is not below the standard of care. Implementation of nonoperative management may result in increased prevalence of sigmoid strictures.
Topics: Diverticulitis, Colonic; Humans; Laparoscopy; Patient Selection
PubMed: 28875302
DOI: 10.1007/s00423-017-1621-6 -
Presse Medicale (Paris, France : 1983) Nov 2015Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under... (Review)
Review
Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.
Topics: Abscess; Acute Disease; Age Factors; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Comorbidity; Dietary Fiber; Disease Management; Disease Progression; Diverticulitis; Drainage; Elective Surgical Procedures; Hospitalization; Humans; Intestinal Perforation; Laparoscopy; Multicenter Studies as Topic; Peritonitis; Probiotics; Randomized Controlled Trials as Topic; Recurrence; Rifamycins; Rifaximin; Therapeutic Irrigation
PubMed: 26358668
DOI: 10.1016/j.lpm.2015.08.004 -
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 -
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 -
BMJ Clinical Evidence Aug 2007Diverticula (mucosal outpouching through the wall of the colon) affect over 5% of adults aged 40 years and older, but only 10-25% of affected people will develop... (Review)
Review
INTRODUCTION
Diverticula (mucosal outpouching through the wall of the colon) affect over 5% of adults aged 40 years and older, but only 10-25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: treatments for uncomplicated diverticular disease; treatments to prevent complications; and treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodics, bran, elective surgery, increasing fibre intake, ispaghula husk, lactulose, medical treatment, mesalazine, methylcellulose, rifaximin, surgery.
Topics: Acute Disease; Diverticulitis; Diverticulitis, Colonic; Diverticulosis, Colonic; Diverticulum; Humans; Mesalamine
PubMed: 19454119
DOI: No ID Found