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JAMA Surgery Jun 2024Care of patients with diverticulitis is undergoing a paradigm shift. This narrative review summarizes the current evidence for left-sided uncomplicated and complicated... (Review)
Review
IMPORTANCE
Care of patients with diverticulitis is undergoing a paradigm shift. This narrative review summarizes the current evidence for left-sided uncomplicated and complicated diverticulitis. The latest pathophysiology, advances in diagnosis, and prevention strategies are also reviewed.
OBSERVATIONS
Treatment is moving to the outpatient setting, physicians are forgoing antibiotics for uncomplicated disease, and the decision for elective surgery for diverticulitis has become preference sensitive. Furthermore, the most current data guiding surgical management of diverticulitis include the adoption of new minimally invasive and robot-assisted techniques.
CONCLUSIONS AND RELEVANCE
This review provides an updated summary of the best practices in the management of diverticulitis to guide colorectal and general surgeons in their treatment of patients with this common disease.
Topics: Humans; Diverticulitis; Diverticulitis, Colonic; Anti-Bacterial Agents; Elective Surgical Procedures; Robotic Surgical Procedures
PubMed: 38630452
DOI: 10.1001/jamasurg.2023.8104 -
Journal of Medical Case Reports Apr 2024Gas extravasation complications arising from perforated diverticulitis are common but manifestations such as pneumoperitoneum, pneumoretroperitoneum, and...
BACKGROUND
Gas extravasation complications arising from perforated diverticulitis are common but manifestations such as pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum happening at the same time are exceedingly rare. This case report explores the unique presentation of these 3 complications occurring simultaneously, their diagnosis and their management, emphasizing the importance of interdisciplinary collaboration for accurate diagnosis and effective management.
CASE PRESENTATION
A 74-year-old North African female, with a medical history including hypertension, dyslipidemia, type 2 diabetes, goiter, prior cholecystectomy, and bilateral total knee replacement, presented with sudden-onset pelvic pain, chronic constipation, and rectal bleeding. Clinical examination revealed hemodynamic instability, hypoxemia, and diffuse tenderness. After appropriate fluid resuscitation with norepinephrine and saline serum, the patient was stable enough to undergo computed tomography scan. Emergency computed tomography scan confirmed perforated diverticulitis at the rectosigmoid junction, accompanied by the unprecedented presence of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum. The patient underwent prompt surgical intervention with colo-rectal resection and a Hartmann colostomy. The postoperative course was favorable, leading to discharge one week after admission.
CONCLUSIONS
This case report highlights the clinical novelty of gas extravasation complications in perforated diverticulitis. The unique triad of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum in a 74-year-old female underscores the diagnostic challenges and the importance of advanced imaging techniques. The successful collaboration between radiologists and surgeons facilitated a timely and accurate diagnosis, enabling a minimally invasive surgical approach. This case contributes to the understanding of atypical presentations of diverticulitis and emphasizes the significance of interdisciplinary teamwork in managing such rare manifestations.
Topics: Humans; Female; Aged; Retropneumoperitoneum; Mediastinal Emphysema; Pneumoperitoneum; Diabetes Mellitus, Type 2; Peritonitis; Diverticulitis; Intestinal Perforation
PubMed: 38627832
DOI: 10.1186/s13256-024-04488-1 -
World Journal of Emergency Surgery :... Apr 2024Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to... (Observational Study)
Observational Study
BACKGROUND
Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.
METHODS
This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.
RESULTS
564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.
CONCLUSIONS
After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.
Topics: Female; Humans; Middle Aged; Aged; Aged, 80 and over; Male; Emergencies; Prospective Studies; Postoperative Complications; Anastomosis, Surgical; Colorectal Neoplasms
PubMed: 38627831
DOI: 10.1186/s13017-024-00543-w -
BMJ Case Reports Apr 2024Acute diverticulitis of the appendix (ADA), though uncommon, often presents similarly to acute appendicitis but carries a higher risk of complications such as...
Acute diverticulitis of the appendix (ADA), though uncommon, often presents similarly to acute appendicitis but carries a higher risk of complications such as perforation and malignancy. We report the case of a male patient in his 50s with acute right iliac fossa abdominal pain, diagnosed via CT scan with ADA. Urgent laparoscopic appendicectomy was performed, and the patient was discharged without further issues. This case highlights the importance of promptly identifying and managing such conditions to minimise complications and improve outcomes. Despite the overlap in symptoms between appendiceal diverticulitis and acute appendicitis, accurate diagnosis is crucial for appropriate treatment. Healthcare providers should maintain a high index of suspicion, particularly in older patients presenting with an acute appendicitis, like clinical picture to ensure timely intervention and optimal patient care.
Topics: Humans; Male; Abdomen, Acute; Abdominal Pain; Acute Disease; Appendectomy; Appendicitis; Appendix; Diagnosis, Differential; Diverticulitis; Pelvic Pain; Middle Aged
PubMed: 38627055
DOI: 10.1136/bcr-2023-259552 -
BMC Surgery Apr 2024Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic...
BACKGROUND
Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications.
METHODS
A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height < 38.5 cm/m in women and < 52.4 cm/m in men.
RESULTS
Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present.
CONCLUSION
Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.
Topics: Humans; Male; Female; Middle Aged; Aged; Sarcopenia; Retrospective Studies; Artificial Intelligence; Anastomosis, Surgical; Treatment Outcome; Colostomy; Proctocolectomy, Restorative; Surgical Wound Infection; Obesity; Postoperative Complications
PubMed: 38622633
DOI: 10.1186/s12893-024-02408-0 -
Cureus Mar 2024As obesity and lifestyle factors become more prevalent in younger populations, we are diagnosing and treating diverticulitis in younger patients. In this study, the...
BACKGROUND
As obesity and lifestyle factors become more prevalent in younger populations, we are diagnosing and treating diverticulitis in younger patients. In this study, the demographics, risk factors for the development, and treatment of acute diverticulitis were assessed focusing on patients under the age of 40.
METHODS
A retrospective review of the electronic medical records of a cohort of subjects diagnosed with diverticulitis was performed. Inclusion criteria included patients aged 18-40 who were treated for acute diverticulitis with or without any complications.
RESULTS
Of the 109 patients, 40 patients required surgery, and 69 patients were managed conservatively. Analysis showed that the Hinchey classification (p<0.001) was the strongest predictor of treatment modality.
CONCLUSIONS
As the incidence of diverticulitis has increased in recent decades, so too has the frequency with which elective surgical procedures are performed as treatment. While these procedures are vital components in the management of diverticulitis, the majority of research comparing conservative versus surgical treatments has been done in patients over 50 years old. Although diverticulitis has been classically thought of as a disease of the elderly, it has become more prevalent in younger populations due to the rise of obesity and lifestyle modification in the under-40 population. Although the prevalence of treatment and diagnosis of acute diverticulitis in younger patients has risen, there is a paucity of data surrounding treatment protocols for diverticulitis in association with patient symptoms for patients under the age of 40 years old. Our study has found that there is a higher incidence of complications in diverticulitis in patients under the age of 40. Additionally, when considering the pattern of complication presentation in younger patients with complicated diverticulitis, surgical intervention might not be appropriate. The current treatment algorithm relates diverticulitis complications with surgical interventions. However, our data suggest that patients under the age of 40 presenting with abscesses or strictures may not need surgical intervention. This information could be particularly helpful in guiding physicians and younger patients in selecting the best choice of care and minimizing complications. Additionally, further research should help guide treatment protocol in this specific population of patients, as there is a lack of established guidelines pertaining to diverticulitis surrounding younger patients.
PubMed: 38618478
DOI: 10.7759/cureus.56190 -
International Journal of Surgery Case... May 2024Small bowel diverticula are a rare entity and are mostly found in the duodenum on diagnosis. Some common complications of this pathology include bleeding, obstruction,...
INTRODUCTION
Small bowel diverticula are a rare entity and are mostly found in the duodenum on diagnosis. Some common complications of this pathology include bleeding, obstruction, diverticulitis, and perforation. Furthermore, there is growing evidence supporting an association between biologic therapies and spontaneous intestinal perforation.
PRESENTATION OF CASE
We present a case of a 79-year-old female on prednisone, hydroxychloroquine, and tofacitinib for rheumatoid arthritis who was misdiagnosed with transverse colonic diverticulitis and eventually found to have perforated jejunal diverticulitis on laparotomy.
DISCUSSION
While tofacitinib has been associated with spontaneous intestinal perforation, it has not been documented as an aggravating factor in small bowel diverticular disease.
CONCLUSION
It is imperative to maintain a high index of suspicion for this pathology in immunosuppressed patients with an atypical presentation of diverticular disease.
PubMed: 38615466
DOI: 10.1016/j.ijscr.2024.109615 -
Scandinavian Journal of Gastroenterology Jul 2024Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear recommendations on whether or not to operate, even though recent studies suggest an improved quality of life following surgery. The aim of this study is therefore to compare quality of life in patients with recurrent or ongoing diverticulitis treated conservatively versus surgically, giving a more definitive answer to the question of whether or not to operate on these patients.
METHODS
A systematic literature search was conducted in EMBASE, MEDLINE and Cochrane. Only comparative studies reporting on quality of life were included. Statistical analysis included calculation of weighted mean differences and pooled odds ratios.
RESULTS
Five studies were included; two RCT's and three retrospective observational studies. Compared to conservative treatment, the SF-36 scores were higher in the surgically treated group at each follow-up moment but only the difference in SF-36 physical scores at six months follow-up was statistically significant (MD 6.02, 95%CI 2.62-9.42). GIQLI scores were also higher in the surgical group with a MD of 14.01 (95%CI 8.15-19.87) at six months follow-up and 7.42 (95%CI 1.23-12.85) at last available follow-up. Also, at last available follow-up, significantly fewer recurrences occurred in the surgery group (OR 0.10, 95%CI 0.05-0.23, < 0.001).
CONCLUSION
Although surgery for recurrent diverticulitis is not without risk, it might improve long-term quality of life in patients suffering from recurrent- or ongoing diverticulitis when compared to conservative treatment. Therefore, it should be considered in this patient group.
Topics: Humans; Quality of Life; Recurrence; Conservative Treatment; Diverticulitis; Diverticulitis, Colonic; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 38613245
DOI: 10.1080/00365521.2024.2337833 -
Surgery Jun 2024The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and...
BACKGROUND
The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.
METHOD
The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.
RESULTS
Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.
CONCLUSION
The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.
Topics: Humans; Retrospective Studies; Female; Male; Middle Aged; Risk Factors; France; Aged; Diverticulitis, Colonic; Emergencies; Adult; Sigmoid Diseases; Aged, 80 and over; Elective Surgical Procedures; Emergency Treatment
PubMed: 38609785
DOI: 10.1016/j.surg.2024.02.009 -
The American Surgeon Apr 2024Colorectal surgery poses significant risks, with anastomotic disruption being a severe complication. Traditional management involves surgical intervention, contributing...
Colorectal surgery poses significant risks, with anastomotic disruption being a severe complication. Traditional management involves surgical intervention, contributing to postoperative morbidity and mortality. In this brief report, we present a 54-year-old woman with a history of diverticulitis, multiple surgeries, and anastomotic leak following ileorectal anastomosis. Attempts at managing anastomotic leaks with more minimally invasive approaches have been successful in esophageal surgery with the use of covered metallic stents. However, this approach has been rarely attempted for the management of colorectal anastomotic leaks. Instead of conventional surgical approaches, we employed an off-label use of an endoscopic covered metallic stent, WallFlex™, to successfully manage the anastomotic disruption. The patient's recovery was uneventful, highlighting the potential role of stents in select cases.
PubMed: 38598522
DOI: 10.1177/00031348241241708