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Minerva Surgery Dec 2022Elective surgery has been proposed, after at least two episodes of acute diverticulitis, initially treated conservatively, in order to prevent further episodes or... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Elective surgery has been proposed, after at least two episodes of acute diverticulitis, initially treated conservatively, in order to prevent further episodes or chronic complaints. However, prophylactic surgery has been questioned, due to the associated risks of postoperative mortality and morbidity, as well as the risk of recurrent diverticulitis. This systematic review attempts to assess the role of prophylactic left colonic resection, after episodes of uncomplicated acute diverticulitis treated either conservatively with antibiotics and/or other supportive measures.
EVIDENCE ACQUISITION
A systematic search was performed using Medline, Embase, Ovid, and Cochrane databases for studies reporting on the treatment of acute uncomplicated diverticulitis (Hinchey I). The main endpoint was treatment failure, defined as persistent/recurrent symptoms or need for readmission and/or reintervention. Secondary endpoints were the immediate postoperative outcomes.
EVIDENCE SYNTHESIS
In total, 24 studies with 2855 patients were included in the analysis. Intra- and postoperative complications rate were 5% and 16%, respectively. Anastomotic leak was 1.3% and emergency reoperation was 2.4%. Long-term symptomatic resolve was reported at 91%. Persistent or recurrent symptoms were observed in 5.4% of cases. Meta-analysis showed no significant difference in recurrence rates between surgical and conservative management.
CONCLUSIONS
Elective surgery to prevent recurrent diverticulitis is not recommended, irrespective of the number of previous episodes. Generally, elective sigmoidectomy should not be recommended to patients with ongoing atypical lower abdominal symptoms after acute diverticulitis, but should aim primarily at improving quality of life. It should be offered to patients with ongoing inflammation, or diverticular complications.
Topics: Humans; Diverticulitis, Colonic; Quality of Life; Recurrence; Diverticulitis; Elective Surgical Procedures
PubMed: 36409040
DOI: 10.23736/S2724-5691.22.09726-X -
World Journal of Emergency Surgery :... Nov 2022There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.
METHODS
A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.
RESULTS
Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8-13%, I = 86%, p < 0.01) in right-sided and 20% (95% CI 16-24%, I = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6-13%, I = 77%, p < 0.01) in right-sided and 15% (95% CI 8-27%, I = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2-10%, I = 84%, p < 0.01) in right-sided and 4% (95% CI 2-7%, I = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.
CONCLUSION
Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.
Topics: Humans; Diverticulitis, Colonic; Risk Factors; Anti-Bacterial Agents
PubMed: 36320045
DOI: 10.1186/s13017-022-00463-7 -
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 -
Journal of Clinical Medicine Aug 2022Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study,... (Review)
Review
Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study, we aimed to synthesize data on previously published cases according to the PRISMA guidelines. A total of 103 patients were included. Patients were more commonly male (71.8%) and had a mean age of 49 years. The most common infection associated with pylephlebitis was diverticulitis ( = 29, 28.2%), and was the most isolated pathogen ( = 21, 20.4%). Blood cultures were positive in 64 cases (62.1%). The most common site of thrombosis was the main portal vein (PV) in 59 patients (57.3%), followed by the superior mesenteric vein (SMV) in 40 patients (38.8%) and the right branch of the PV in 30 patients (29.1%). Sepsis developed in 60 patients (58.3%). The mortality rate in our review was 8.7%, and independent risk factors for mortality were the presence of pertinent comorbidities (OR 5.5, = 0.02), positive blood cultures (OR 2.2, = 0.02), and sepsis (OR 17.2, = 0.049).
PubMed: 36078922
DOI: 10.3390/jcm11174992 -
Surgical Laparoscopy, Endoscopy &... Oct 2022Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze...
PURPOSE
Colovesical fistula (CVF) is a rare complication of sigmoid diverticulitis causing significant morbidity and quality of life impairment. Aim of this study was to analyze contemporary literature data to appraise the current standard of care and changes of treatment algorithms over time.
MATERIALS AND METHODS
A systematic review of the literature on surgical management of CVF was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines.
RESULTS
Fourteen papers published between 2014 and 2020 and including 1061 patients were analyzed. One-stage colonic resection with primary anastomosis, with or without loop ileostomy, was the most common surgical procedure. A laparoscopic or robotic approach was attempted in 39.5% of patients, and conversion rate to open surgery was 7.8%. Clavien-Dindo grade ≥3 complication rate, 30-day mortality, and recurrence rate were 7.4%, 1.5%, and 0.5%, respectively.
CONCLUSIONS
Minimally invasive sigmoidectomy with primary anastomosis is safe and should be the first-choice approach for CVF. Bladder repair is not necessary after a negative intraoperative leak test. A standardized perioperative care can improve clinical outcomes and reduce the length of hospital stay and the duration of Foley catheterization.
Topics: Colon, Sigmoid; Conversion to Open Surgery; Diverticulitis, Colonic; Humans; Intestinal Fistula; Laparoscopy; Postoperative Complications; Quality of Life; Treatment Outcome
PubMed: 36044282
DOI: 10.1097/SLE.0000000000001099 -
International Journal of Colorectal... Sep 2022The aim of this review was to examine if diverticulitis increases the long-term risk (> 6 months) of developing colon cancer. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of this review was to examine if diverticulitis increases the long-term risk (> 6 months) of developing colon cancer.
METHODS
A systematic search was conducted in PubMed, Embase, and Cochrane CENTRAL. Google Scholar was also searched. We included studies with human adults of 18 years of age and above. Studies that included only patients with diverticulitis as well as studies comparing groups with and without diverticulitis were included. The primary outcome was the incidence of colon cancer 6 months or more after an episode of diverticulitis.
RESULTS
Twelve records were included with 38,621 patients with diverticulitis. The crude rate of colon cancer among the prospectively followed populations with diverticulitis was by meta-analysis found to be 0.6% (95% CI 0.5-0.6%). The limitations of this review include heterogeneous reporting of outcomes across studies, specifically regarding population and outcome as well as variations in the design and reporting of the studies.
CONCLUSION
We found that the long-term risk of colon cancer after diverticulitis is not increased. The results of our review support current practice on follow-up after an episode of diverticulitis with short-term follow-up being the primary focus.
Topics: Adult; Colonic Neoplasms; Diverticulitis; Diverticulitis, Colonic; Humans
PubMed: 36042030
DOI: 10.1007/s00384-022-04246-z -
Digestive Diseases and Sciences Mar 2023Growing evidence supports the role of the intestinal microbiome in the development of different intestinal and extraintestinal diseases. Diverticular disease (DD) is one...
INTRODUCTION
Growing evidence supports the role of the intestinal microbiome in the development of different intestinal and extraintestinal diseases. Diverticular disease (DD) is one of the most common disorders in western countries. In the last years, different articles have suggested a possible role of the intestinal microbiome in DD pathogenesis and in the development of acute diverticulitis (AD). This systematic review aimed to clarify the current knowledge on the role of the intestinal microbiome in colonic diverticulitis in different stages according to the 2009 PRISMA guidelines.
MATERIALS AND METHODS
Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, Cochrane Oral Health Group Specialized Register, ProQuest Dissertations and Theses Database, and Google Scholar. Patients with any stage of disease were included. The Newcastle-Ottawa scale for case-control and cohort studies was used for the quality assessment of the selected articles.
RESULTS
Overall, nine studies were included in the review. Only one article was focused on patients with AD, while all other articles only considered patients with DD without acute inflammation signs. Enterobacteriaceae seems to be the microbiota most associated with the disease, followed by Bifidobacteria.
CONCLUSIONS
All the included studies showed great heterogeneity in population characteristics and sampling methods. Therefore, given the high prevalence of colonic diverticulitis in the general population, further studies are needed to clarify the role of the intestinal microbiome, paving the way to new target therapies with important social implications.
Topics: Humans; Diverticulitis, Colonic; Gastrointestinal Microbiome; Diverticular Diseases; Diverticulitis; Intestines
PubMed: 35796855
DOI: 10.1007/s10620-022-07600-x -
Scandinavian Journal of Surgery : SJS :... 2022The aim of this systematic review was to evaluate the risk of parastomal (PSH) and incisional hernias (IH) after emergency surgery for Hinchey III-IV diverticulitis,...
PURPOSE
The aim of this systematic review was to evaluate the risk of parastomal (PSH) and incisional hernias (IH) after emergency surgery for Hinchey III-IV diverticulitis, with comparison between the Hartmann procedure and other surgical techniques.
METHODS
The Cochrane Library, Embase, PubMed (MEDLINE), Web of Science and Scopus databases were systematically searched. The primary endpoint was parastomal hernia incidence. The secondary endpoint was incisional hernia incidence.
RESULTS
Five studies (four randomized controlled trials and one retrospective cohort) with a total of 699 patients were eligible for inclusion. The PSH rate was 15%-46% for Hartmann procedure, 0%-85% for primary anastomosis, 4% for resection, and 2% for laparoscopic lavage. The IH rates were 5%-38% for Hartmann procedure, 5%-27% for primary anastomosis, 9%-12% for primary resection, and 3%-11% for laparoscopic lavage.
CONCLUSIONS
Both the parastomal and incisional hernia incidences are poorly evaluated and reported, and varied greatly between the studies.
Topics: Anastomosis, Surgical; Diverticulitis; Humans; Incidence; Incisional Hernia; Laparoscopy; Randomized Controlled Trials as Topic; Retrospective Studies
PubMed: 35748305
DOI: 10.1177/14574969221107276 -
The Cochrane Database of Systematic... Jun 2022Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis... (Review)
Review
BACKGROUND
Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable.
OBJECTIVES
The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery.
SEARCH METHODS
For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021.
SELECTION CRITERIA
Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality.
DATA COLLECTION AND ANALYSIS
Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method.
MAIN RESULTS
The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information. For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited.
AUTHORS' CONCLUSIONS
The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.
Topics: Anti-Bacterial Agents; Colon; Diverticulitis; Humans; Length of Stay
PubMed: 35731704
DOI: 10.1002/14651858.CD009092.pub3 -
International Journal of Colorectal... Mar 2022The role of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid in the occurrence of diverticular bleeding (DB), complicated diverticulitis (CD), and... (Meta-Analysis)
Meta-Analysis Review
Non-steroidal anti-inflammatory drugs and acetylsalicylic acid increase the risk of complications of diverticular disease: a meta-analysis of case-control and cohort studies.
BACKGROUND
The role of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid in the occurrence of diverticular bleeding (DB), complicated diverticulitis (CD), and acute diverticulitis (AD) is not yet defined.
AIM
Update a systematic review and meta-analyses of case-control and cohort studies to evaluate the association between NSAIDs or acetylsalicylic acid with DB, CD, or AD.
METHODS
The study included were identified through MEDLINE, Scopus, Web of Science, and Cochrane Library databases. Sizes were pooled across studies to obtain the overall effect size. A random-effects model was used to account for different sources of variation among studies. Odds ratio (OR) with 95% confidence interval (CI) was used as a measure of effect size.
RESULTS
Thirteen studies were included in the systematic review and meta-analysis. NSAIDs and acetylsalicylic acid use were associated with an increased risk of DB (OR: 6.90, 95% CI 3.86 to 12.35, P ˂ 0.00001, and OR 2.84, 95% CI 2.19 to 3.67, P < 0.00001, respectively). NSAIDs and acetylsalicylic acid use were also associated with increased risk of CD occurrence (OR 3.13, 95% CI 1.73 to 5.68, P = 0.0002, and OR 1.49, 95% CI 1.02 to 2.17, P = 0.04, respectively). The only study found about AD occurrence showed that NSAIDs use was not associated with AD and acetylsalicylic acid use had a low risk of AD.
CONCLUSION
NSAIDs and acetylsalicylic acid significantly increase the risk of DB and CD. Further studies are needed to clarify the role of NSAIDs and acetylsalicylic acid in AD. However, increasing evidence suggests caution in the use of such medications in patients with colonic diverticula.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Case-Control Studies; Cohort Studies; Diverticulum, Colon; Humans; Pharmaceutical Preparations
PubMed: 35094111
DOI: 10.1007/s00384-021-04088-1