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Nutrients Feb 2017Symptomatic uncomplicated diverticular disease (SUDD) is a syndrome characterized by recurrent abdominal symptoms in patients with colonic diverticula. There is some... (Review)
Review
Symptomatic uncomplicated diverticular disease (SUDD) is a syndrome characterized by recurrent abdominal symptoms in patients with colonic diverticula. There is some evidence that a high-fiber diet or supplemental fibers may reduce symptoms in SUDD patients and a high-fiber diet is commonly suggested for these patients. This systematic review aims to update the evidence on the efficacy of fiber treatment in SUDD, in terms of a reduction in symptoms and the prevention of acute diverticulitis. According to PRISMA, we identified studies on SUDD patients treated with fibers (PubMed and Scopus). The quality of these studies was evaluated by the Jadad scale. The main outcome measures were a reduction of abdominal symptoms and the prevention of acute diverticulitis. Nineteen studies were included, nine with dietary fiber and 10 with supplemental fiber, with a high heterogeneity concerning the quantity and quality of fibers employed. Single studies suggest that fibers, both dietary and supplemental, could be beneficial in SUDD, even if the quality is very low, with just one study yielding an optimal score. The presence of substantial methodological limitations, the heterogeneity of the therapeutic regimens employed, and the lack of ad hoc designed studies, did not permit a summary of the outcome measure. Thus, the benefit of dietary or supplemental fiber in SUDD patients still needs to be established.
Topics: Databases, Factual; Dietary Fiber; Diverticulosis, Colonic; Humans; Meta-Analysis as Topic; Randomized Controlled Trials as Topic
PubMed: 28230737
DOI: 10.3390/nu9020161 -
International Journal of Surgery... Feb 2017Laparoscopic peritoneal lavage (LPL) has been proposed as an alternative, less invasive technique in the treatment of acute perforated sigmoid diverticulitis (APSD). The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic peritoneal lavage (LPL) has been proposed as an alternative, less invasive technique in the treatment of acute perforated sigmoid diverticulitis (APSD). The aim of this meta-analysis is to compare the effectiveness of LPL versus surgical resection (SR) in terms of morbidity and mortality in the management of APSD.
METHODS
A comprehensive search was conducted for randomised controlled trials (RCTs) comparing LPL versus SR in the treatment of APSD. The end points included peri-operative mortality, severe adverse events, overall mortality, post-operative abscess, percutaneous reinterventions, reoperation, operative time, postoperative stay, and readmissions.
RESULTS
Three RCTs with a total of 372 patients, randomised to either LPL or SR were included. There was no significant difference in peri-operative mortality between LPL and SR (OR 1.356, 95% CI 0.365 to 5.032, p = 0.649), or serious adverse events (OR = 1.866, 95% CI = 0.680 to 5.120, p = 0.226). The LPL required significantly less time to complete than SR (WMD = -72.105, 95% CI = -88.335 to -55.876, p < 0.0001). The LPL group was associated with a significantly higher rate of postoperative abscess formation (OR = 4.121, 95% CI = 1.890 to 8.986, p = 0.0004) and subsequent percutaneous interventions (OR = 5.414, 95% CI 1.618 to 18.118, p = 0.006).
CONCLUSION
Laparoscopic peritoneal lavage is a safe and quick alternative in the management of APSD. In comparison to SR, LPL results in higher rates of postoperative abscess formation requiring more percutaneous drainage interventions without any difference in perioperative mortality and serious morbidity.
Topics: Diverticulitis, Colonic; Humans; Intestinal Perforation; Laparoscopy; Peritoneal Lavage; Randomized Controlled Trials as Topic; Reoperation; Treatment Outcome
PubMed: 28089941
DOI: 10.1016/j.ijsu.2017.01.020 -
International Journal of Surgery... Nov 2016This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly,... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.
METHODS
PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.
RESULTS
Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.
CONCLUSIONS
Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.
Topics: Abdominal Abscess; Acute Disease; Anti-Bacterial Agents; Colectomy; Diverticulitis, Colonic; Drainage; Humans; Observational Studies as Topic; Recurrence; Treatment Failure
PubMed: 27741423
DOI: 10.1016/j.ijsu.2016.10.006 -
United European Gastroenterology Journal Oct 2016The surgical treatment of diverticulitis is in a state of evolution. Clinicians across many disciplines need to counsel patients regarding surgical choices. (Review)
Review
BACKGROUND
The surgical treatment of diverticulitis is in a state of evolution. Clinicians across many disciplines need to counsel patients regarding surgical choices.
OBJECTIVES
A systematic review and meta-analysis was conducted to determine the mortality and complication rates following surgery for diverticulitis in both the emergent and elective setting.
METHODS
We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published from 1980 to 2012. The primary outcome of interest was the point estimate of mortality, following surgery for diverticulitis.
RESULTS
Of the 289 citations reviewed, we included 59 studies. Overall, the point estimate for mortality was 3.05%, with a 95% confidence intereval (CI) of 1.73-5.32 and < 0.001. Mortality following emergent surgery was 10.64% (95% CI 7.95-14.11; < 0.001), versus 0.50% (95% CI 0.46-0.54; < 0.001) following elective operations. A laparoscopic approach had an estimated mortality of 0.75% (95% CI 0.35-1.58; < 0.001), compared to an open surgical approach, which had a mortality of 4.69% (95% CI 2.29-9.36, < 0.001). The mortality following a resection with primary anastomosis was 1.96% (95% CI 1.22-3.13; < 0.001) and for the Hartmann's procedure was 14.18% (95% CI 9.83-20.03; < 0.001). A comparative analysis found that the risk of post-operative mortality was significantly higher following emergent surgery, compared to elective surgery (odds ratio (OR): 6.12 with 95% CI 1.62-23.10; = 0.008; = 2.56, = 0.46 and I= 0); the open approach, compared to a laparoscopic approach (OR: 36.43 with 95% CI 9.94-133.6; = 0.13; and = 2.79, = 0.25 and = 28.26); and for Hartmann's procedure, compared to primary anastomosis without diversion (OR: 25.45 with 95% CI 15.13-42.81, < 0.001; and = 23.34, = 0.14 and = 27.16). The overall reported post-operative complication rate was 32.64% (95% CI 27.43-38.32; < 0.00). The overall surgical and medical complication rates were 18.96% and 13.93%, respectively.
CONCLUSIONS
Urgent surgical treatment of diverticulitis has a significant complication rate. Even elective surgery has a significant complication rate that needs to be considered when doing the clinical decision-making for recurrent diverticulitis.
PubMed: 27733913
DOI: 10.1177/2050640615617357 -
Digestive Surgery 2017Management of diverticular disease has undergone a paradigm shift, with movement towards a less invasive management strategy. In keeping with this, outpatient management... (Comparative Study)
Comparative Study Review
BACKGROUND
Management of diverticular disease has undergone a paradigm shift, with movement towards a less invasive management strategy. In keeping with this, outpatient management of uncomplicated diverticulitis (UD) has been advocated in several studies, but concerns still remain regarding the safety of this practice.
AIM
To assess outcomes of out-patient management of acute UD.
METHODS
A comprehensive search for published studies using the search terms 'uncomplicated diverticulitis', 'mild diverticulitis' and 'out-patient' was performed. The primary outcomes were failure of medical treatment. Secondary outcomes were recurrence rate at follow up and medical cost savings.
RESULTS
The search yielded 192 publications. Of these, 10 studies met the inclusion criteria including 1 randomized controlled trial, 6 clinical controlled trials and 3 case series. There was no difference in failure rates of medical treatment (6.5 vs. 4.6%, p = 0.32) or in recurrence rates (13.0 vs. 12.1%, p = 0.81) between those receiving ambulatory care and in-patient care for UD. Ambulatory treatment is associated with an estimated daily cost savings of between 600 and 1,900 euros per patient treated. Meta-analysis of data was not possible due to heterogeneity in study designs and inclusion criteria.
CONCLUSION
Ambulatory management of acute UD is reasonable in selected patients.
Topics: Acute Disease; Ambulatory Care; Analgesics; Anti-Bacterial Agents; Cost Savings; Diet; Diverticulitis; Health Care Costs; Hospitalization; Humans; Recurrence; Severity of Illness Index; Treatment Failure
PubMed: 27701164
DOI: 10.1159/000450865 -
World Journal of Emergency Surgery :... 2016Due to the increasing number of solid organs transplantations, emergency abdominal surgery in transplanted patients is becoming a relevant challenge for the general... (Review)
Review
AIMS
Due to the increasing number of solid organs transplantations, emergency abdominal surgery in transplanted patients is becoming a relevant challenge for the general surgeon. The aim of this systematic review of the literature is to analyze morbidity and mortality of emergency abdominal surgery performed in transplanted patients for graft-unrelated surgical problems.
METHODS
The literature search was performed on online databases with the time limit 1990-2015. Studies describing all types of emergency abdominal surgery in solid organ transplanted patients were retrieved for evaluation.
RESULTS
Thirty-nine case series published between 1996 and 2015 met the inclusion criteria and were selected for the systematic review. Overall, they included 71671 transplanted patients, of which 1761 (2.5 %) underwent emergency abdominal surgery. The transplanted organs were the heart in 65.8 % of patients, the lung in 22.1 %, the kidney in 9.5 %, and the liver in 2.6 %. The mean patients' age at the time of the emergency abdominal surgery was 49.4 ± 7.4 years, and the median time from transplantation to emergency surgery was 2.4 years (range 0.1-20). Indications for emergency abdominal surgery were: gallbladder diseases (80.3 %), gastrointestinal perforations (9.2 %), complicated diverticulitis (6.2 %), small bowel obstructions (2 %), and appendicitis (2 %). The overall mortality was 5.5 % (range 0-17.5 %). The morbidity rate varied from 13.6 % for gallbladder diseases to 32.7 % for complicated diverticulitis. Most of the time, the immunosuppressive therapy was maintained unmodified postoperatively.
CONCLUSIONS
Emergency abdominal surgery in transplanted patients is not a rare event. Although associated with relevant mortality and morbidity, a prompt and appropriate surgery can lead to satisfactory results if performed taking into account the patient's immunosuppression therapy and hemodynamic stability.
PubMed: 27582783
DOI: 10.1186/s13017-016-0101-6 -
Journal of Gastrointestinal and Liver... Mar 2016Diverticular disease is a common gastrointestinal condition. Low-grade inflammation and altered intestinal microbiota have been identified as factors contributing to... (Review)
Review
BACKGROUND AND AIMS
Diverticular disease is a common gastrointestinal condition. Low-grade inflammation and altered intestinal microbiota have been identified as factors contributing to abdominal symptoms. Probiotics may lead to symptoms improvement by modifying the gut microbiota and are promising treatments for diverticular disease. The aim of this study was to systematically review the efficacy of probiotics in diverticular disease in terms of remission of abdominal symptoms and prevention of acute diverticulitis.
METHODS
According to PRISMA, we identified studies on diverticular disease patients treated with probiotics (Pubmed, Embase, Cochrane). The quality of these studies was evaluated by the Jadad scale. Main outcomes measures were remission of abdominal symptoms and prevention of acute diverticulitis.
RESULTS
11 studies (2 double-blind randomized placebo-controlled, 5 open randomized, 4 non-randomized open studies) were eligible. Overall, diverticular disease patients were 764 (55.1% females, age 58-75 years). Three studies included patients with symptomatic uncomplicated diverticular disease, 4 studies with symptomatic uncomplicated diverticular disease in remission, 4 studies with complicated or acute diverticulitis. Mainly (72.7%) single probiotic strains had been used, most frequently Lactobacilli. Follow-up ranged from 1 to 24 months. Interventions were variable: in 8 studies the probiotic was administered together with antibiotic or anti-inflammatory agents and compared with the efficacy of the drug alone; in 3 studies the probiotic was compared with a high-fibre diet or used together with phytoextracts. As an outcome measure, 4 studies evaluated the occurrence rate of acute diverticulitis, 6 studies the reduction of abdominal symptoms, and 6 studies the recurrence of abdominal symptoms. Meta-analysis on the efficacy of probiotics in diverticular disease could not be performed due to the poor quality of retrieved studies.
CONCLUSION
This systematic review showed that high-quality data on the efficacy of probiotics in diverticular disease are scant: the available data do not permit conclusions. Further investigation is required to understand how probiotics can be employed in this condition.
Topics: Diverticulitis; Gastrointestinal Microbiome; Humans; Intestines; Probiotics; Remission Induction; Treatment Outcome
PubMed: 27014757
DOI: 10.15403/jgld.2014.1121.251.srw -
Journal of the American Heart... Mar 2016A considerable amount of studies have examined the relationship between off-hours (weekends and nights) admission and mortality risk for various diseases, but the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A considerable amount of studies have examined the relationship between off-hours (weekends and nights) admission and mortality risk for various diseases, but the results remain equivocal.
METHODS AND RESULTS
Through a search of EMBASE, PUBMED, Web of Science, and Cochrane Database of Systematic Reviews, we identified cohort studies that evaluated the association between off-hour admission and mortality risk for disease. In a random effects meta-analysis of 140 identified articles (251 cohorts), off-hour admission was strongly associated with increased mortality for aortic aneurysm (odds ratio, 1.52; 95% CI, 1.30-1.77), breast cancer (1.50, 1.21-1.86), leukemia (1.45, 1.17-1.79), respiratory neoplasm (1.32, 1.20-1.26), pancreatic cancer (1.32, 1.12-1.56), malignant neoplasm of genitourinary organs (1.27, 1.08-1.49), colorectal cancer (1.26, 1.07-1.49), pulmonary embolism (1.20, 1.13-1.28), arrhythmia and cardiac arrest (1.19, 1.09-1.29), and lymphoma (1.19, 1.06-1.34). Weaker (odds ratio <1.19) but statistically significant association was noted for renal failure, traumatic brain injury, heart failure, intracerebral hemorrhage, subarachnoid hemorrhage, stroke, gastrointestinal bleeding, myocardial infarction, chronic obstructive pulmonary disease, and bloodstream infections. No association was found for hip fracture, pneumonia, intestinal obstruction, aspiration pneumonia, peptic ulcer, trauma, diverticulitis, and neonatal mortality. Overall, off-hour admission was associated with increased mortality for 28 diseases combined (odds ratio, 1.11; 95% CI, 1.10-1.13).
CONCLUSIONS
Off-hour admission is associated with increased mortality risk, and the associations varied substantially for different diseases. Specialists, nurses, as well as hospital administrators and health policymakers can take these findings into consideration to improve the quality and continuity of medical services.
Topics: After-Hours Care; Cardiovascular Diseases; Cause of Death; Chi-Square Distribution; Communicable Diseases; Gastrointestinal Diseases; Hospital Mortality; Humans; Kidney Diseases; Neoplasms; Odds Ratio; Patient Admission; Prognosis; Regression Analysis; Respiratory Tract Diseases; Risk Assessment; Risk Factors; Time Factors
PubMed: 26994132
DOI: 10.1161/JAHA.115.003102 -
International Journal of Surgery... Feb 2016Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring... (Review)
Review
BACKGROUND
Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis.
METHODS
A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death.
RESULTS
Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity.
CONCLUSION
A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.
Topics: Acute Disease; Anti-Inflammatory Agents, Non-Steroidal; C-Reactive Protein; Comorbidity; Diverticulitis; Glucocorticoids; Humans; Severity of Illness Index; Tomography, X-Ray Computed
PubMed: 26777741
DOI: 10.1016/j.ijsu.2016.01.005 -
International Journal of Surgery... Dec 2015Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open... (Review)
Review
INTRODUCTION
Laparoscopic surgery is considered in the treatment of diverticular fistula for the possible reduction of overall morbidity and complication rate if compared to open surgery. Aim of this review is to assess the possible advantages deriving from a laparoscopic approach in the treatment of diverticular fistulas of the colon.
METHODS
Studies presenting at least 10 adult patients who underwent laparoscopic surgery for sigmoid diverticular fistula were reviewed. Fistula recurrence, reintervention, Hartmann's procedure or proximal diversion, conversion to laparotomy were the outcomes considered.
RESULTS
11 non randomized studies were included. Rates of fistula recurrence (0.8%), early reintervention (30 days) (2%) and need for Hartmann's procedure or proximal diversion (1.4%) did not show significant difference between laparoscopy and open technique.
DISCUSSION
there is still concern about which surgery in complicated diverticulitis should be preferred. Laparoscopic approach has led to less postoperative pain, shorter hospital stay, faster recovery and better cosmetic results. Laparoscopic resection and primary anastomosis is a possible approach to sigmoid fistulas but its advantages in terms of lower mortality rate and postoperative stay after colon resection with primary anastomosis should be interpreted with caution. When there is firm evidence supporting it, it is likely that minimally invasive surgery should become the standard approach for diverticular fistulas, thus achieving adequate exposure and better visualization of the surgical field.
CONCLUSION
The lack of RCTs, the small sample size, the heterogeneity of literature do not allow to draw statistically significant conclusions on the laparoscopic surgery for fistulas despite this approach is considered safe.
Topics: Colectomy; Colon, Sigmoid; Diverticulitis, Colonic; Humans; Intestinal Fistula; Laparoscopy
PubMed: 26584958
DOI: 10.1016/j.ijsu.2015.11.007