Complicated Colonic Diverticular Disease Research Articles

Novel Endoscopic Management of Colovesical Fistula Secondary to Colonic Diverticular Disease

AbstractColovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Most common cause is complicated colonic diverticular disease. The treatment of choice for CVF is surgery. Conservative treatment is reserved for highly selected patients who are unfit for definitive surgery. We report the case of an 86-year-old gentleman with multiple comorbidities, who presented with pneumaturia, fecaluria, and recurrent urinary tract infection. He was diagnosed to have sigmoid colonic diverticulosis with a CVF and was successfully managed with the novel combined endoscopic approach (a simultaneous cystoscopy and flexible colonoscopy), which could be the first to be reported from India.

Factors Affecting the Colonoscopic Cecal Intubation Failure in Patients With Complicated Diverticular Disease of the Colon by a Pericolic Infiltrate

Introduction: Cecal intubation rate is an important indicator of colonoscopy quality. But incomplete colonoscopy is higher in patients with chronic, recurrent, complicated colonic diverticular disease due to the risk of complications. We assessed the frequency, factors of the cecal intubation failure in patients with complicated diverticular disease of the colon by a pericolic infiltrate. Methods: Patients operated on for the diverticular disease of the colon complicated by a pericolic infiltrate, confirmed by the morphological study were retrospectively included in the study. Diverticular disease duration was over 6 month with recurrent attacks following treatment. All patients underwent unsedated pre-operative colonoscopy. The parameters studied were age, gender, colonoscopic parameters: complications; cecal intubation rate (CIR); cecal intubation failure rate; external colon compression, narrowing of the lumen and colonic wall edema; tall, thickened, swollen folds of the colon; fixed colonic segments in a limited area; pus; the hemorrhagic component - petechiae, erosions. Results: Thirty-two patients were included (mean age 55,6+12,3 years, M:F = 17:15). All 32 colonoscopic examinations were carried out without complications. We have identified CIR=43,7%, cecal intubation failure rate=56,3%. Analysis of the incidence of the endoscopic imaging parameters showed that the most common signs are the local wall hyperemic area (84,8%) and fixed colonic segments in a limited area (81,2%). The incidence of other endoscopic signs ranged from 31,2% to 56,2%. The comparative analysis revealed that a significant difference in the cecal intubation failure associated only with the external colon compression, narrowing of the lumen and colonic wall edema (Fisher's two-tailed exact test - 0,0092, p < 0,05). Analysis evaluated that the external colon compression, narrowing of the lumen and colonic wall edema is a significant prognostic indicator of the pericolic infiltrate with positive predictive value 100%. Conclusion: Our results show that the external colon compression, narrowing of the lumen and colonic wall edema is valid diagnostic criteria of the pericolic infiltrate in patients with complicated diverticular disease of the colon and at the same time it is the factor affecting the colonoscopic cecal intubation failure in these patients.Figure: External colon compression, narrowing of the lumen and colonic wall edema.Figure: Tall, thickened, swollen folds of the colon.Figure: The hemorrhagic component - petechiae, erosions.

Laparoscopic treatment of complicated colonic diverticular disease: A review.

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann's procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review.

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Complications of diverticular disease: surgical laparoscopic treatment

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of our study was to evaluate the outcome of laparoscopic colon resection in patients with diverticulitis and with complications like colon-vescical fistula, peridiverticular abscess, perforation or stricture. All patients underwent laparoscopic colectomy within 8 years period. Main data recorded were age, sex, return of bowel function, operation time, duration of hospital stay, ASA score, body mass index (BMI), early and late complications. During the study period, 33 colon resections were performed for diverticulitis and complications of diverticulitis. We performed 5 associated procedures. We had 2 postoperative complications; 1 of these required a redo operation with laparotomy for anastomotic leak and 3 patients required conversion from laparoscopic to open colectomy. The most common reasons for conversion were related to the inflammatory process with a severe adhesion syndrome. Mean operative time was 229 minutes, and average postoperative hospital stay was 9,8 days. Laparoscopic surgery for complications of diverticular disease is safe, effective and feasible. Laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis in our institution.

Role of acute diverticulitis in the development of complicated colonic diverticular disease and 1-year mortality after diagnosis in the UK: population-based cohort study

ObjectiveTo determine the risk of developing complicated colonic diverticular disease (CCDD) with prior episodes of acute diverticulitis and determine the mortality of the spectrum of CCDD.DesignPopulation-based cohort study.SettingComputerised records from...

M1256 The Relationship Between Abdominal Fat Amount and the Diverticular Disease

Aim. The aim of this study was to assess the role of fecal calprotectin (FC) in diagnosis of complicated colonic diverticular disease (DD) and to compare it with uncomplicated colonic DD and matched controls. Methods. We studied 57 consecutive patients with a new endoscopic diagnosis of colonic diverticulosis (45 with asymptomatic uncomplicated DD, and 12 with acute diverticulitis) and 25 healthy controls. The level of FC was measured in every case by a semiquantitative test with three categories of results: type 1 (under 15 μg/g), type 2 (15-60 μg/g), and type 3 (more than 60 μg/g). The results were correlated with the degree of histological inflammation of colonic mucosa that was assessed by the degree of lymphocytic cell density. Results. We found higher FC values in acute uncomplicated diverticulitis (p<0.05) than in asymptomatic uncomplicated DD and in healthy controls. There were no differences between uncomplicated colonic DD and healthy controls. FC values increase according to the increase of lymphocytic cell density, showing a statistically significant correlation (p<0. 05). Patients with acute diverticulitis were treated with antibiotics for 10 days; in these patients, reassessment of FC after three months revealed a significant decrease comparingwith the initial level. Conclusions. FCmay be useful to detect colonic inflammation in DD and in distinguishing acute diverticulitis from uncomplicated colonic DD and healthy controls. Also, FC may be useful for follow-up after treatment.

M1255 Fecal Calprotectin in Diagnosis of Complicated Colonic Diverticular Disease

M1255 Fecal Calprotectin in Diagnosis of Complicated Colonic Diverticular Disease

Laparoscopic Sigmoidectomy for Diverticulitis: a Prospective Study

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis. All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications. During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%). Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

Health-Related Quality of Life after Colonic Resection for Diverticular Disease: Long-term Results

Background and AimsWhile colonic resection is standard practice in complicated colonic diverticular disease (DD), treatment of uncomplicated diverticulitis is, as yet, unclear. The aim of the present study was to evaluate the long-term clinical outcome and quality of life in DD patients undergoing colonic resection compared to those receiving medical treatment only. Patients and MethodsSeventy-one consecutive patients who were admitted to our surgical department with left iliac pain and endoscopical or radiological diagnosis of DD were enrolled in this trial. Disease severity was assessed with Hinchey scale. Twenty-five of the patients underwent colonic resection, while 46 were treated with medical therapy alone. After a median follow-up of 47 (3–102) months from the time of their first hospital admission, the patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. Admittance and surgical procedures for DD were also investigated, and surgery- and symptoms-free survival rates were calculated. Nonparametric tests and survival analysis were used. ResultsThe CGQL total scores and symptom frequency rate were found to be similar in the two groups (resection vs nonresection). Only current quality of health item was significantly worse in patients who had undergone colonic resection (p = 0.05). No difference was found in the rate and in the timing of surgical procedures and hospital admitting for DD in the two groups. In particular, the nine patients classified as Hinchey 1 who underwent surgery reported the same quality of life, symptoms frequency, operation, and hospital admitting rate as those who had been admitted with the same disease class but who received medical treatment only. ConclusionsOur results indicate that there does not seem to be any long-term advantage to colonic resection which should be considered only in patients presenting complicated DD.

Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England

BackgroundComplicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment.MethodsThis is a retrospective study of all patients who were admitted to the surgical ward between May 2002 and November 2006 with a diagnosis of complicated diverticular disease. A proforma of patients' details, admission date, ITU admission, management outcomes and the follow up were recorded from the patients case notes and analyzed. The mean follow-up was 34 months (range 6–60 months)ResultsThe mean age of patients was 72.7 years (range 39–87 years). Thirty-one men (28.18 %) and Seventy-nine women (71.81%) were included in this study. Male: female ratio was 1:2.5.Sixty-eight percent of patients had one or more co-morbidities. Forty-one patients (37.27%) had two or more episodes of diverticulitis while 41.8% of them had no history of diverticular disease.Eighty-six percent of patients presented with acute abdominal pain while bleeding per rectum was the main presentation in 14%. Constipation and erratic bowel habit were the commonest chronic symptoms in patients with history of diverticular disease. Generalized tenderness was reported in 64.28% while 35.71% have left iliac fossa tenderness. Leukocytosis was reported in 58 patients (52.72%).The mean time from the admission until the start of operative intervention was 20.57 hours (range 4–96 hours). Perforation was confirmed in 59.52%. Mortality was 10.90%. Another 4 (3.63%) died during follow up for other reasons.ConclusionComplicated diverticular disease carries significant morbidity and mortality. These influenced by patient-related factors. Because of high mortality and morbidities, we suggest the need to target a specific group of patients for prophylactic resection.

Colonic Diverticular Disease: Current Perspectives

Diverticular disease is a common condition affecting large intestine in the western world, which, although remains asymptomatic in majority of people, can present with abdominal pain, acute diverticulitis, perforation, haemorrhage, intestinal obstruction and fistulation through neighbouring organs. Complicated colonic diverticular disease (CDD) is associated with significant morbidity and mortality. Increasing urbanisation globally with intake of diet deficient in fibres has led to CDD as a significant problem; hence awareness of CDD is paramount for its prevention and appropriate management. The purpose of this article is to provide a comprehensive review of the epidemiology, pathophysiology, clinical presentations, and current management of diverticular disease of the colon and its complications.

Is laparoscopic surgery applicable to complicated colonic diverticular disease?

Expanding upon our experience with laparoscopic surgery for colonic benign and malignant processes and for bowel obstruction, we have reviewed our experience with minimal access laparoscopic surgery for complicated diverticular disease. We propose an approach of surgical care incorporating diagnostic laparoscopy in those not responding to medical therapy alone. Our study includes data from two different surgical teams working in separate hospital-and-patient environments. Our theory that laparoscopy could be widely applicable to this complex disease process is borne out by experience in both locations. One hundred forty-eight patients were managed by laparoscopic or laparoscopically assisted methods with 18 patients requiring drainage only without resection. Our management of 148 of 164 patients (90%) by laparoscopic approach was successful, with a very acceptable morbidity of 5% in the elective cases and decreased ileus (20% of open vs 7% laparoscopic) in acute complicated cases. Elective resections required hospitalization of 4-5 days, demonstrating the benefits of incorporating laparoscopy in the care of these cases, particularly when compared to standard open procedures requiring 8 days' hospitalization. We believe complications of diverticular disease including abscess, perforation, fistula, and bleeding can potentially be managed in this way by minimal access procedures, decreasing postoperative wound problems, decreasing length of hospitalization and overall morbidity, and improving patient care.