CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study

Nicola Flor,Perry J Pickhardt,Giovanni Di Leo,Valeria Merlo,Giovanni Maconi,Monica Falleni,Silvia Panella

doi:10.1007/s00261-020-02690-5

Abstract

PurposeTo perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).MethodsFifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0–3 point scale for each variable.ResultsOf 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.ConclusionDDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.

Highlights

Diverticular disease represents the most common disease affecting the colon in the Western world [1]
Preoperative CT colonography (CTC) findings were available to the surgeons, who followed the World Gastroenterology Organization surgical guidelines for diverticular disease [16]
The colon segment affected by acute diverticulitis (AD) was resected, extending the resection according to the vascular pedicle, severity, and extension of diverticular disease

Summary

Introduction

Diverticular disease represents the most common disease affecting the colon in the Western world [1]. In patients who have clinically recovered from an episode of AD, CTC gives detailed information on the extent of diverticular disease; the main CTC findings in cases of severe diverticular disease include marked colonic wall thickening, typically involving a long segment, associated with severe luminal stenosis [11, 12]. These CTC findings are key findings for the DDSS classification of disease severity based on CTC [13]. DDSS has proved to have predictive value for the course of the disease [14], and marked wall thickening (DDSS score of 4) generally signifies the presence of chronic inflammation with fibrosis

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Results

Conclusion