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Medicina (Kaunas, Lithuania) Nov 2019: The diverticular disease includes a broad spectrum of different "clinical situations" from diverticulosis to acute diverticulitis (AD), with a full spectrum of...
: The diverticular disease includes a broad spectrum of different "clinical situations" from diverticulosis to acute diverticulitis (AD), with a full spectrum of severity ranging from self-limiting infection to abscess or fistula formation to free perforation. The present work aimed to assess the burden of complicated diverticulitis through a comparative analysis of the hospitalizations based on the national administrative databases. : A review of the international and national administrative databases concerning admissions for complicated AD was performed. : Ten studies met the inclusion criteria and were included in the analysis. No definition of acute complicated diverticulitis was reported in any study. Complicated AD accounted for approximately 42% and 79% of the hospitalizations. The reported rates of abscess varied between 1% and 10% from all admissions for AD and 5-29% of the cases with complicated AD. An increasing temporal trend was found in one study-from 6% to 10%. The rates of diffuse peritonitis ranged from 1.6% to 10.2% of all hospitalizations and 11% and 47% of the complicated cases and were stable in the time. : The available data precluded definitive conclusions because of the significant discrepancy between the included studies. The leading cause was the presence of heterogeneity due to coding inaccuracies in all databases, absence of ICD codes to distinguish the different type of complications, and the lack of coding data about some general conditions such as sepsis, shock, malnutrition, steroid therapy, diabetes, pulmonary, and heart failure.
Topics: Abscess; Diverticulitis, Colonic; Humans; Registries
PubMed: 31744067
DOI: 10.3390/medicina55110744 -
International Journal of Surgery... Nov 2019Diverticulitis is one of the most common gastrointestinal diseases in western population. Colonic resection is recommended by international guidelines as a routinely... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Diverticulitis is one of the most common gastrointestinal diseases in western population. Colonic resection is recommended by international guidelines as a routinely used technique for purulent diverticulitis. Laparoscopic lavage was introduced as a non-resection alternative. The studies available so far have shown contradictory results. This meta-analysis aims to compare laparoscopic lavage versus colonic resection in patients with Hinchey Ⅲ-Ⅳ diverticulitis.
METHODS
We did a systematic review of articles published before March 20, 2019, with no language restriction by searching PubMed, Cochrane library, EMBASE databases, clinicaltrials.gov, and Google Scholar databases. We included all RCTs and cohort studies comparing outcomes between patients with Hinchey Ⅲ-Ⅳ diverticulitis undergoing laparoscopic lavage versus colonic resection. Important outcomes were mortality, complications, length of stay, readmission and reoperation rates. We combined data to assess the outcomes using DerSimonian and Laird random-effects model.
RESULTS
A total of 569 patients with diverticulitis of which more than 80% were Hinchey Ⅲ were enrolled from 3 RCTs and 5 cohort studies. Laparoscopic lavage was associated with shorter operative time (WMD -78.9, 95%CI -100.58 to -57.11, P < 0.0001) and total postoperative hospital stay (WMD -7.62, 95%CI -11.60 to -3.63, P = 0.0002) but a higher rate of intra-abdominal abscess (OR 2.69, 95%CI 1.39 to 5.21, P = 0.0032) and secondary peritonitis (OR 5.30, 95%CI 1.91 to 14.73, P = 0.0014).
CONCLUSION
Laparoscopic lavage for patients with Hinchey Ⅲ to Ⅳ diverticulitis does provide similar mortality, shorter operative time and hospital stay. However, the evidence so far suggests that it might be inadequate for sepsis control and may result in more unplanned reoperations. Further studies are needed to standardize the formal indication for laparoscopic lavage.
Topics: Abdominal Abscess; Adult; Aged; Colectomy; Diverticulitis, Colonic; Female; Humans; Laparoscopy; Length of Stay; Male; Middle Aged; Operative Time; Peritoneal Lavage; Peritonitis; Postoperative Complications; Postoperative Period; Reoperation; Treatment Outcome
PubMed: 31610284
DOI: 10.1016/j.ijsu.2019.10.007 -
World Journal of Emergency Surgery :... 2019Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Surgical management of Hinchey III and IV diverticulitis utilizes either Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. The aim of this meta-analysis is to determine which of the two procedures has a more favorable outcome.
METHODS
A systematic review of the existing literature was performed using the PRISMA guidelines. A meta-analysis was carried out using a Mantel-Haenszel, random effects model, and forest plots were generated. The Newcastle-Ottawa and Jadad scoring tools were used to assess the included studies.
RESULTS
A total of 25 studies involving 3546 patients were included in this study. The overall mortality in the HP group was 10.8% across the observational studies and 9.4% in the randomized controlled trials (RCTs). The mortality rate in the PRA group was lower than that in the HP group, at 8.2% in the observational studies and 4.3% in the RCTs. A comparison of PRA vs HP demonstrated a 40% lower mortality rate in the PRA group than in the HP (OR 0.60, 95% CI 0.38-0.95, = 0.03) when analyzing the observational studies. However, meta-analysis of the three RCTs did not demonstrate any difference in mortality, (OR 0.44 (95% CI 0.14-1.34, = 0.15). Wound infection rates between the two groups were comparable (OR 0.75, 95% CI 0.20-2.78, = 0.67).
CONCLUSION
Analysis of observational studies suggests that PRA may be associated with a lower overall mortality. There were no differences in wound infection rates. Based on the current evidence, both surgical strategies appear to be acceptable.
Topics: Anastomosis, Surgical; Diverticulitis, Colonic; Humans; Intestinal Perforation; Peritonitis
PubMed: 31338117
DOI: 10.1186/s13017-019-0251-4 -
Frontiers in Pediatrics 2019Our aim was to highlight the characteristics of pediatric Meckel's diverticulum with a special focus on its complications. We report a group of seven patients with...
Our aim was to highlight the characteristics of pediatric Meckel's diverticulum with a special focus on its complications. We report a group of seven patients with Meckel's diverticulum and its resection from the Department of Pediatric Surgery between 2012 and 2017. We reviewed all patient records, clinical presentation, and intraoperative findings. The diagnosis was confirmed by surgery and pathology. For a systematic literature review, we used PubMed, Medline and Google Scholar search engines to locate articles containing terms such as Meckel's diverticulum, children, pediatric, complications and symptomatic. We included article reporting on case series in English and German on pediatric patients only. All included patients ( = 7) were symptomatic. Some patients showed isolated symptoms, and others presented with a combination of symptoms that consisted of abdominal pain, bloody stool or vomiting. The median age of our seven cases was 3.5 years, including 4 male and 3 female patients. Intestinal obstruction was the most common complication; it was seen in 5 out of 7 patients (intussusception in 4 cases, volvulus in 1 case). Ectopic gastric tissue was identified in 3 cases, and inclusion of pancreatic tissue was observed in 1 case. The literature review identified 8 articles for a total of 641 patients aged between 1 day and 17 years and a male:female ratio of 2.6:1. From this group, 528 patients showed clinical symptoms related to Meckel's diverticulum. The most common symptom was abdominal pain and bloody stool. The most common surgical finding in symptomatic patients was intestinal obstruction (41%), followed by intestinal hemorrhage (34%). Complications such as perforation (10%) and diverticulitis (13%) were less frequently reported. Heterotopic tissue was confirmed on histopathology in 53% of all patients enclosing gastric, pancreatic, and both gastric and pancreatic mucosae. In one case, large intestine tissue could be found. Overall, one death was reported. The presented case series and literature review found similar clinical presentations and complications of Meckel's diverticulum in children. Intestinal obstruction and bleeding are more frequent than inflammation in pediatric Meckel's diverticulum. Bowel obstruction is the leading cause for complicated Meckel's diverticulum in patients younger than 12 years.
PubMed: 31294008
DOI: 10.3389/fped.2019.00267 -
The British Journal of Surgery Jul 2019Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT-proven acute diverticulitis.
METHODS
PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT-proven left-sided acute diverticulitis. The prevalence was pooled using a random-effects model and, if possible, compared with that among asymptomatic controls.
RESULTS
Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent.
CONCLUSION
Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.
Topics: Acute Disease; Colonoscopy; Colorectal Neoplasms; Diverticulitis; Humans; Prevalence; Tomography, X-Ray Computed
PubMed: 31260589
DOI: 10.1002/bjs.11191 -
European Journal of Nutrition Mar 2020A high intake of dietary fibre has been associated with a reduced risk of diverticular disease in several studies; however, the dose-response relationship between fibre... (Meta-Analysis)
Meta-Analysis
BACKGROUND
A high intake of dietary fibre has been associated with a reduced risk of diverticular disease in several studies; however, the dose-response relationship between fibre intake and diverticular disease risk has varied, and the available studies have not been summarised in a meta-analysis. We conducted a systematic review and meta-analysis of prospective cohort studies to clarify the association between dietary fibre intake, fibre subtypes, and the risk of diverticular disease.
METHODS
PubMed and Embase databases were searched up to August 9th 2018. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model and nonlinear associations were modelled using fractional polynomial models.
RESULTS
Five prospective cohort studies with 19,282 cases and 865,829 participants were included in the analysis of dietary fibre and diverticular disease risk. The summary RR was 0.74 (95% CI 0.71-0.78, I = 0%) per 10 g/day. There was no evidence of a nonlinear association between dietary fibre intake and diverticular disease risk, p = 0.35, and there was a 23%, 41% and 58% reduction in risk for an intake of 20, 30, and 40 g/day, respectively, compared to 7.5 g/day. There was no evidence of publication bias with Egger's test, p = 0.58 and the association persisted in subgroup and sensitivity analyses. The summary RR per 10 g/day was 0.74 (95% CI 0.67-0.81, I = 60%, n = 4) for cereal fibre, 0.56 (95% CI 0.37-0.84, I = 73%, n = 2) for fruit fibre, and 0.80 (95% CI 0.45-1.44, I = 87%, n = 2) for vegetable fibre.
CONCLUSIONS
These results suggest that a high fibre intake may reduce the risk of diverticular disease and individuals consuming 30 g of fibre per day have a 41% reduction in risk compared to persons with a low fibre intake. Further studies are needed on fibre types and risk of diverticular disease and diverticulitis.
Topics: Dietary Fiber; Diverticular Diseases; Humans; Prospective Studies; Risk Assessment
PubMed: 31037341
DOI: 10.1007/s00394-019-01967-w -
Revista de Gastroenterologia de Mexico... 2019Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología,...
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
Topics: Colonic Diseases; Consensus; Delphi Technique; Diverticular Diseases; Diverticulitis; Guidelines as Topic; Humans; Mexico
PubMed: 31014749
DOI: 10.1016/j.rgmx.2019.01.002 -
Canadian Journal of Gastroenterology &... 2018Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms.
BACKGROUND
Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms.
AIM
We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease.
METHODS
We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi and I tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration.
RESULTS
We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24).
CONCLUSIONS
Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Diverticular Diseases; Diverticulitis; Diverticulum, Colon; Female; Humans; Male; Mesalamine; Quality of Life; Randomized Controlled Trials as Topic; Risk Assessment; Treatment Outcome
PubMed: 30320044
DOI: 10.1155/2018/5437135 -
Journal of Gastrointestinal and Liver... Sep 2018Symptomatic Uncomplicated Diverticular disease (SUDD) affects about 25% of patients harboring colonic diverticula. We assessed the effectiveness of mesalazine in... (Meta-Analysis)
Meta-Analysis
Mesalazine to treat symptomatic uncomplicated diverticular disease and to prevent acute diverticulitis occurrence. A systematic review with meta-analysis of randomized, placebo-controlled trials.
BACKGROUND AND AIMS
Symptomatic Uncomplicated Diverticular disease (SUDD) affects about 25% of patients harboring colonic diverticula. We assessed the effectiveness of mesalazine in improving symptoms (namely abdominal pain, primary outcome) and in preventing diverticulitis occurrence (secondary outcome) in patients with SUDD.
METHODS
Pertinent studies were selected from the Medline and the Cochrane Central Register of Controlled Trials. Only randomized clinical trials (RCTs) (irrespective of language, blinding, or publication status), which compared mesalazine, irrespective of the dosage assumption, with placebo in SUDD were evaluated.
RESULTS
Four RCTs enrolled 379 patients, 197 treated with mesalazine and 182 with placebo. Two studies provided data on symptom relief according to definition: it was achieved in 97/121 (80%) patients in the mesalazine group and in 81/129 (62.7%) patients in the placebo group (OR 0.43; 95% CI 0.24-0.75; p=0.003 in favour of the mesalazine group). Two studies provided information regarding occurrence of diverticulitis during follow-up. It occurred in 23/119 (19.3%) patients in the mesalazine group and in 34/102 (33.3%) patients in the placebo group (OR 0.35; 95% CI 0.17-0.70; p=0.003 in favour of the mesalazine group).
CONCLUSIONS
Treatment with mesalazine seems to be effective in achieving symptom relief and in the primary prevention of diverticulitis in patients with SUDD.
Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Diverticulitis, Colonic; Diverticulum, Colon; Female; Gastrointestinal Agents; Humans; Male; Mesalamine; Middle Aged; Primary Prevention; Randomized Controlled Trials as Topic; Risk Factors; Time Factors; Treatment Outcome; Young Adult
PubMed: 30240473
DOI: 10.15403/jgld.2014.1121.273.pic -
International Journal of Surgery... Oct 2018No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We... (Meta-Analysis)
Meta-Analysis
BACKGROUND
No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature.
METHODS
Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted.
RESULTS
The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%.
CONCLUSION
Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.
Topics: Adult; Anastomosis, Surgical; Bias; Diverticulitis, Colonic; Humans; Intestinal Perforation; Morbidity; Prospective Studies; Retrospective Studies
PubMed: 30165109
DOI: 10.1016/j.ijsu.2018.08.009