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Annals of Internal Medicine Mar 2022The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic...
DESCRIPTION
The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.
METHODS
The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.
TARGET AUDIENCE AND PATIENT POPULATION
The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis.
RECOMMENDATION 1
RECOMMENDATION 2
RECOMMENDATION 3
Topics: Adult; Diverticulitis, Colonic; Hospitalization; Humans; Outcome Assessment, Health Care; Physicians; United States
PubMed: 35038273
DOI: 10.7326/M21-2710 -
Annals of Internal Medicine Mar 2022Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.
BACKGROUND
Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.
PURPOSE
To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.
DATA SOURCES
MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.
STUDY SELECTION
Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.
DATA EXTRACTION
6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.
DATA SYNTHESIS
Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).
LIMITATIONS
The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.
CONCLUSION
Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.
PRIMARY FUNDING SOURCE
Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).
Topics: Acute Disease; Anti-Bacterial Agents; Diagnostic Imaging; Diverticulitis; Diverticulitis, Colonic; Humans
PubMed: 35038271
DOI: 10.7326/M21-1645 -
Annals of Internal Medicine Mar 2022The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal...
Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians.
DESCRIPTION
The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.
METHODS
The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.
TARGET AUDIENCE AND PATIENT POPULATION
The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.
RECOMMENDATION 1
RECOMMENDATION 2
RECOMMENDATION 3
Topics: Adult; Colonoscopy; Diverticulitis, Colonic; Humans; Physicians; United States
PubMed: 35038270
DOI: 10.7326/M21-2711 -
Annals of Internal Medicine Mar 2022The value of interventions used after acute colonic diverticulitis is unclear.
BACKGROUND
The value of interventions used after acute colonic diverticulitis is unclear.
PURPOSE
To evaluate postdiverticulitis colonoscopy and interventions to prevent recurrent diverticulitis.
DATA SOURCES
MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.
STUDY SELECTION
Comparative studies of interventions of interest reporting critical or important outcomes, and larger single-group studies to evaluate prevalence of colonoscopy findings and harms.
DATA EXTRACTION
6 researchers extracted study data and risk of bias. The team assessed strength of evidence.
DATA SYNTHESIS
19 studies evaluated colonoscopy. Risk for prevalent colorectal cancer (CRC) compared with the general population is unclear. Based on low-strength evidence, long-term CRC diagnosis is similar with or without colonoscopy. High-strength evidence indicates that risk for prevalent CRC is higher among patients with complicated diverticulitis and colonoscopy complications are rare. Based on high-strength evidence, mesalamine does not reduce recurrence risk (6 randomized controlled trials [RCTs]). Evidence on other nonsurgical interventions is insufficient. For patients with prior complicated or smoldering or frequently recurrent diverticulitis, elective surgery is associated with reduced recurrence (3 studies; high strength). In 19 studies, serious surgical complications were uncommon.
LIMITATIONS
Few RCTs provided evidence. Heterogeneity of treatment effect was not adequately assessed.
CONCLUSION
It is unclear whether patients with recent acute diverticulitis are at increased risk for prevalent CRC, but those with complicated diverticulitis are at increased risk. Mesalamine is ineffective in preventing recurrence; other nonsurgical treatments have inadequate evidence. Elective surgery reduces recurrence in patients with prior complicated or smoldering or frequently recurrent diverticulitis, but it is unclear which of these patients may benefit most.
PRIMARY FUNDING SOURCE
Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).
Topics: Colonoscopy; Diverticulitis; Diverticulitis, Colonic; Humans; Mesalamine; United States
PubMed: 35038269
DOI: 10.7326/M21-1646 -
Annals of Internal Medicine Mar 2022
PubMed: 35038267
DOI: 10.7326/M22-0156 -
Journal of Digestive Diseases Feb 2022There is no consensus on the optimal treatment for patients with complicated diverticulitis. In this systematic review and meta-analysis we aimed to determine the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
There is no consensus on the optimal treatment for patients with complicated diverticulitis. In this systematic review and meta-analysis we aimed to determine the indications for elective surgery in complicated diverticulitis by comparing conservative treatment with elective surgery.
METHODS
A meta-analysis of recurrence, morbidity and stoma rates was performed using a random effects model. Patient-reported quality of life (QoL) and cost-effectiveness outcomes were synthesized qualitatively.
RESULTS
Eleven randomized controlled trials and non-randomized studies with a total of 7415 patients were included. In statistical terms, the recurrence of diverticulitis was significantly higher in the conservatively treated group than in the elective surgery group (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.51). The stoma rate (OR 2.34, 95% CI 1.88-2.92) and the morbidity rate (OR 4.29, 95% CI 2.24-8.23) were significantly higher in the elective surgery group than in the conservatively treated group. There was some evidence for a significant increase in QoL and long-term cost-effectiveness in the elective surgery group than in the conservatively treated group.
CONCLUSIONS
Indications for elective surgery should not include the prevention of emergency colostomy or complications. Elective surgical resection may be considered in patients with complicated diverticulitis with the goal of improving their QoL and long-term cost-effectiveness.
Topics: Conservative Treatment; Diverticulitis; Elective Surgical Procedures; Humans; Quality of Life; Randomized Controlled Trials as Topic; Recurrence
PubMed: 34965017
DOI: 10.1111/1751-2980.13076 -
Minerva Urology and Nephrology Aug 2022Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with...
INTRODUCTION
Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with urological signs such as pneumaturia and fecaluria. Diagnostic investigations aim at confirming the presence of a fistula. Although conservative management can be chosen for selected individuals, most patients are mainly treated through surgical interventions. CVF represents a challenging condition, which records high rates of morbidity and mortality. Our systematic review aimed at achieving deeper knowledge of both indications, in addition to short- and long-term outcomes related to CVF management.
EVIDENCE ACQUISITION
We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.
EVIDENCE SYNTHESIS
The 22 included articles covered an approximately 37 years-study period (1982-2019), with a total 1365 patient population. CVF etiology was colonic diverticulitis in most cases (87.9%). Pneumaturia (50.1%), fecaluria (40.9%) and urinary tract infections (46.6%) were the most common symptoms. Abdomen computed tomography (CT) scan (80.5%), colonoscopy (74.5%) and cystoscopy (55.9%) were the most frequently performed diagnostic methods. Most CVF patients underwent surgery (97.1%) with open approach (63.3%). Almost all patients had colorectal resection with primary anastomosis with or without ostomy and 53.2% patients underwent primary repair or partial/total cystectomy. Four percent anastomotic leak, 1.8% bladder leak and 3.1% reoperations rates were identified. In an average 5-68-month follow-up, overall morbidity, overall mortality and recurrences rates recorded were 8-49%, 0-63% and 1.2%, respectively.
CONCLUSIONS
CVF mainly affects males and has diverticular origin in almost all cases. Pneumaturia, fecaluria and urinary tract infections are the most characteristic symptoms. Endoscopic tests and imaging are critical tools for diagnostic completion. Management of CVFs depends on the underlying disease. Surgical treatment represents the final approach and consists of resection and reanastomosis of offending intestinal segment, with or without bladder closure. In many cases, a single-stage surgical strategy is selected. Perioperative and long-term outcomes prove good.
Topics: Colon, Sigmoid; Colonoscopy; Diverticulitis, Colonic; Diverticulum; Humans; Intestinal Fistula; Male; Urinary Bladder Fistula
PubMed: 34791866
DOI: 10.23736/S2724-6051.21.04750-9 -
International Journal of Colorectal... Jan 2022Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature.
METHODS
The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome.
RESULTS
The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001).
CONCLUSION
Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.
Topics: Colectomy; Diverticular Diseases; Humans; Laparoscopy; Length of Stay; Postoperative Complications; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34599362
DOI: 10.1007/s00384-021-04038-x -
Surgery Feb 2022The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins.
METHODS
MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis.
RESULTS
Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, P < 0.001; I = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, P < 0.001; I = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy.
CONCLUSION
According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis.
Topics: Acute Disease; Anti-Bacterial Agents; Delphi Technique; Disease Progression; Diverticulitis, Colonic; Equivalence Trials as Topic; Humans; Treatment Outcome; Watchful Waiting
PubMed: 34344525
DOI: 10.1016/j.surg.2021.07.012 -
Colorectal Disease : the Official... Oct 2021Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies... (Review)
Review
AIM
Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management.
METHODS
This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD.
RESULTS
Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%).
CONCLUSION
CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.
Topics: Appendectomy; Appendicitis; Cecal Diseases; Diagnosis, Differential; Diagnostic Errors; Diverticulitis; Humans
PubMed: 34272795
DOI: 10.1111/codi.15818