Hinchey Stage Research Articles

A Decade of Follow-Up to Assess the Risk of Recurrence and Surgery after a First Episode of Uncomplicated Left-Sided Diverticulitis

Background and aims: Acute uncomplicated diverticulitis (UD) of the left colon is common and mostly benign. Due to controversy over the definition of UD and the lack of adequate follow-up in most studies, good quality data to predict long-term outcomes after a first episode of UD are missing. The aim of this study was to assess the long-term risk for adverse outcomes after a first episode of UD. Methods: All consecutive patients with a CT-scan-documented first episode of acute UD (staged “uncomplicated” according to ESCP guidelines and/or modified Hinchey stages 0-1a, and/or CDD 1-2a) between January 2010 and June 2013 were included in the study. CT scans and clinical records were retrospectively reviewed. The primary endpoint was overall recurrence; the secondary endpoint was surgery for diverticular disease. Results: One hundred and five patients were included in the study with a median follow-up of 116.4 (4.9–154.7) months. Of these, 51 (48.5%) patients had a recurrence, 11 (10.4%) had 4 or more episodes. Twenty-one (20%) patients underwent sigmoidectomy, all in an elective setting, mostly due to multiple recurrent episodes. Male gender was the only independent risk factor for surgery (OR (95%CI): 0.301 (0.109–0.834), p = 0.021). Classification systems did not predict recurrence, but stage CDD 1a was protective for surgery (OR (95%CI): 0.201 (0.042–0.957), p = 0.044). Conclusions: After a decade of follow-up, almost half the patients experienced at least one recurrent episode after UD, higher than previously thought. None of those patients required emergency surgery, but one in five patients, mostly men, underwent elective sigmoidectomy for multiple recurrent episodes.

Case Report: A 31-Year-Old Man with Relapsing Complicated Diverticulitis after Initial Conservative Treatment

BACKGROUND: There is controversy regarding the surgical approach for severe complications of diverticular disease. The classical approach has been a Hartmann’s procedure, but laparoscopic lavage and drainage has been suggested as an alternative. We present a patient who initially responded to conservative management of complicated diverticulitis, but had a recurrence that was managed surgically. CASE PRESENTATION: A 31-year-old man presented with Hinchey Stage I diverticulitis and was discharged from the hospital after medical management. Six days later, he returned to the hospital with radiographic evidence of a pericolonic abscess. The patient was taken to the operating room for laparoscopic drainage with placement of a drain in the abscess cavity. He required reoperation with sigmoid colon resection, primary anastomosis, and diverting ileostomy. DISCUSSION: Despite requiring reoperation, the authors believe that initial conservative management possibly prevented progression to generalized feculent peritonitis. If this had occurred, the patient may have required Hartmann’s procedure, which is associated with more complications than primary anastomosis with protective ileostomy. CONCLUSION: The patient had recurrence of complicated diverticular disease that was initially managed conservatively and then with laparoscopic drainage, followed by primary anastomosis with protective ileostomy. Given individual patient factors, the authors believe that he was managed optimally. There is currently controversy between the use of laparoscopic lavage and drainage versus Hartmann’s procedure for the management of complicated colonic diverticular disease and more investigation is required on the subject.

Diverticulitis Surgery Outcomes: Insights from Our Clinical Practice

Aim: To assess outcomes of diverticulitis surgery, focusing on various patient phases at a tertiary center and incorporating literature insights. Materials and Method: Analysis included diverticular disease surgeries at *** University's General Surgery Clinic over five years, examining demographics, disease specifics, surgical details, stoma aspects, and complications. Patients were categorized into emergency and elective groups for comparison based on Hinchey scores and stoma status. Results: Of the patients, 72% were male, with an average age of 58.46. The sigmoid colon was predominantly affected (84%). Percutaneous drainage was used preoperatively in 44%, and 56% required a stoma, primarily Hartmann colostomies (36%). The median stoma closure time was 5 months, with 10 patients unable to have their stoma closed. Emergency surgeries were associated with higher Hinchey stages (III-IV) and an increased need for stoma creation (81% vs. 16% in elective surgeries). Conclusion: The study indicates a median 5-month duration for stoma reversal, with sigmoid colon being the common site regardless of gender. Emergency surgeries showed a higher rate of stoma creation, suggesting elective surgeries could reduce stoma necessity. Further investigation is needed for broader applicability.

Features of colonic diverticulitis in children and adolescents: A multicenter study

Colonic diverticulitis (CD), typically seen in the elderly of Western countries, is increasingly prevalent worldwide, yet data on CD in children and adolescents are scarce. This study explores the characteristics of CD in this younger demographic. In a multicenter, retrospective review, 104 patients under 20 years diagnosed with CD at four Korean tertiary hospitals from June 2003 to December 2020 were analyzed. Abdominal CT scans were used for diagnosis, with the modified Hinchey classification assessing the severity of CD. CD was found in the cecum or ascending colon in 103 (99%) of cases. The mean patient age was 17.24 ± 2.4 years, with males constituting 59.6% of cases. Solitary lesions were noted in 93 (89.4%) of patients. Severity was classified as modified Hinchey stage 0 in 58.7%, stage Ia in 29.8%, and stage Ib in 11.5%, with no cases of stage II or higher. Misdiagnosis as acute appendicitis occurred in six instances. IV antibiotics were administered to 68.3%, and oral antibiotics were sufficient for 24%. Surgical treatment was necessary for two patients. A 7.8% recurrence rate was noted among first-time CD patients, yetall cases were amenable to conservative management. While uncommon, CD in children and adolescents is a growing concern, with most cases presenting as solitary lesions in the cecum or ascending colon. The severity is typically less than that in adults, and conservative treatment is generally effective. These findings underscore the need for specific management guidelines for pediatric CD, advocating for non-surgical initial approaches.

Antibiotic Practice in Patients With Acute Abdomen Admitted to a Danish Regional Hospital: A Clinical Qualitative Assurance Study.

Background Acute abdomen is often complicated by intra-abdominal infection requiring antibiotic therapy. Danish regional antibiotic guidelines emphasize the restricted use of broad-spectrum antibiotics such as cephalosporins. In this study, we aimed to evaluate antibiotic practices in relation to hospitalized patients with acute abdomen. Methodology This retrospective quality assurance study was conducted among patients admitted to the surgical emergency department at the North Denmark Regional Hospital during a four-month observation period. Data were extracted from electronic patient journals and entered in the Research Electronic Data Capture data management system for further analytical work. Results Of 331 patients, 174 (53%) were treated with antibiotics, of whom 98 (56%) had been treated with cephalosporin, 47 (27%) with benzylpenicillin and gentamicin, 22 (13%) with piperacillin/tazobactam, and seven (4%) with ciprofloxacin. Use of a cephalosporin-based antibiotic regimen was significantly more common in patients with acute appendicitis (75%) compared to other diagnostic groups, such as acute cholecystitis (57%), incarcerated hernia with strangulation (56%), acute pancreatitis (50%), and acute diverticulitis (30%). However, patients with uncomplicated diverticulitis (53%) were significantly more often treated with benzylpenicillin and gentamicin, whereas patients with complicated diverticulitis Hinchey stage 3-4 were significantly more often treated with piperacillin/tazobactam. In addition, as the severity of acute cholecystitis increased, it was more frequently treated with piperacillin/tazobactam. Conclusions The study revealed that cephalosporins are frequently used in patients hospitalized with acute abdomen. This finding conflicts with current regional antibiotic guidelines. Reinforcement of the guidelines is required as an essential measure against the development of antibiotic resistance associated with the use of cephalosporins.

The suspended ileal loop for difficult Hartmann's reversal.

Hartmann's reversal can be complicated by the presence of dense adhesions in the upper part of the abdominal cavity, difficulties in freeing the splenic flexure with the risk of splenic tears, a lack of sufficient colonic length, the risk of ureteral lesion, or the risk of lesions of the vascular arcade. We propose a technique which consists of interposing an adapted segment of ileal loop between the end of the proximal colon and the rectum to restore intestinal continuity. Two patients had Hartmann procedure, the first for a Hinchey stage 4 perforated diverticulitis and the second for a colorectal fistula due to ischemia of the proximal colonic segment. Hartmann's reversal was expected to be difficult, so a suspended ileal loop was used. The outcomes were uneventful, and functional results were satisfactory. A suspended ileal loop could be used as a salvage procedure in some cases of potentially difficult Hartmann's reversal.

Procedimiento de Hartmann vs. anastomosis primaria para diverticulitis Hinchey III: estudio prospectivo de casos y controles

IntroductionHartmann's procedure (HP) is the conventional treatment in patients with complicated diverticulitis. Segmental resection with primary anastomosis (PA) is a treatment alternative for those patients. Our aim was to compare the postoperative results of HP and PA in patients with complicated diverticulitis (Hinchey stage III). MethodsA case-control study was conducted on patients operated on for purulent Hinchey stage III diverticulitis, within the time frame of 2000 and 2019. ResultsTwenty-seven patients that underwent PA were compared with 27 that underwent HP. The patients that underwent HP had a greater probability of morbidity at 30 days (OR 3.5; 95% CI 1.13-11.25), as well as a greater probability of major complications (OR 10.9; 95% CI 1.26-95.05). ConclusionThe patients that underwent segmental resection and PA presented with lower morbidity rates and higher stoma reversal rates than the patients that underwent HP.

Hartmann’s procedure versus primary anastomosis for Hinchey stage III diverticulitis: a prospective case-control study

IntroductionHartmann’s procedure (HP) is the conventional treatment in patients with complicated diverticulitis. Segmental resection with primary anastomosis (PA) is a treatment alternative for those patients. Our aim was to compare the postoperative results of HP and PA in patients with complicated diverticulitis (Hinchey stage III). MethodsA case-control study was conducted on patients operated on for purulent Hinchey stage III diverticulitis, within the time frame of 2000 and 2019. ResultsTwenty-seven patients that underwent PA were compared with 27 that underwent HP. The patients that underwent HP had a greater probability of morbidity at 30 days (OR 3.5; 95% CI 1.13–11.25), as well as a greater probability of major complications (OR 10.9; 95% CI 1.26–95.05). ConclusionThe patients that underwent segmental resection and PA presented with lower morbidity rates and higher stoma reversal rates than the patients that underwent HP.

Investigation of the clinical features and recurrence patterns of acute right-sided colonic diverticulitis: A retrospective cohort study

BackgroundRight-sided colonic diverticulitis (RCD) and left-sided colonic diverticulitis (LCD) are considered distinct diseases. However, separate guidelines for RCD do not exist. Since the establishment of RCD management would first require evaluation of disease characteristics and recurrence patterns, this study has aimed to investigate the differences in the clinical characteristics between RCD and LCD and the recurrence patterns of RCD. MethodsPatients admitted for colonic diverticulitis between January 2012 and August 2020 were retrospectively reviewed. Clinical characteristics and recurrence rates in RCD and LCD patients, and predictors for recurrence and the recurrence patterns of RCD were analyzed. ResultsIn total, 446 colonic diverticulitis patients (343 RCD, 103 LCD) were included in this study. RCD patients were more likely to be male, younger, taller, heavier, smoke, drink alcohol, have better physical performance scores, lower modified Hinchey stages and better initial laboratory findings. LCD patients were more likely to receive invasive treatments, have longer fasting and hospital days, higher mortality and cumulative recurrence rates (20.5% vs. 30.4%, P = 0.007). Recurrences in most RCD patients were of similar disease severity and received the same treatments for initial attacks, with rates of recurrence increasing after each recurrence. Predictors of the recurrence of RCD were complicated diverticulitis (hazard ratio[HR] 2.512, 95% confidence interval[CI] 0.127–5.599, p = 0.024) and percutaneous drainage (HR 6.549, 95% CI 1.535–27.930, p = 0.011). ConclusionRCD is less severe and has a lower recurrence rate than LCD, suggesting that RCD should be treated conservatively. Patients with complicated diseases and those requiring percutaneous drainage are more likely to experience a disease recurrence, suggesting nonsurgical management may be insufficient.

WE1.10 Acute Diverticulitis: Are We Following National & International Guidance On Antimicrobial Strategy For Uncomplicated Cases?

Abstract Aims Uncomplicated acute diverticulitis is conventionally treated with antibiotics. Emerging evidence has suggested a non-antimicrobial approach in systemically well patients is a safe alternative strategy. Our aim was to assess adherence to national (NICE) & international (WJES) guidelines for uncomplicated cases. Methodology Data was gathered from PACS imaging & discharge summaries retrospectively (1st October 2020–1st March 2021).The inclusion criteria was: CT confirmed cases of modified Hinchey stage 0 or 1a. The cohort was stratified into systemically well or unwell based on: admission CRP <150, observation score <2 (NICE sepsis stratification), immunocompetance status & Charlson score <3, as evidenced in the literature. Results There were 48 patients included (female 29 vs male 19). The number of systemically well patients was 32 (67%) & unwell 16 (33%). Compliance to guidance 1 (NICE) - ‘systemically well & therefore no antibiotics’, was low with only 2/32 (6%) patients. Of the remaining, 14/30 (47%) were given intravenous antibiotics. Compliance to guidance 2 (NICE) - ‘systemically unwell & therefore oral antibiotics’, was 4/16 (25%) with the remaining majority of 12/16 (75%) treated with intravenous form. The median number of inpatient nights was 1.48 (well: 1.28 vs unwell: 1.88). Conclusions The majority of patients with uncomplicated diverticulitis were systemically well. Compliance with guidelines on antimicrobial strategy was low. The incorporation of a risk stratification tool as demonstrated, allows for identification of patients that be discharged (with ambulatory follow up) after assessment. CT scans should be reviewed by radiologists with a multidisciplinary discussion on the most appropriate antimicrobial strategy.

EP.FRI.12Meta-analysis of demographic and prognostic significance of right-sided versus left-sided acute diverticulitis

Abstract Aims To compare the demographic and prognostic outcomes of right-sided versus left-sided acute colonic diverticulitis Methods We performed a systematic review in accordance with the PRISMA statement standards to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis. We used the ROBINS-I tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients (MD:-14.16,P<0.00001) and more male patients (OR:1.33,P=0.02) compared with left-sided diverticulitis. Smoking (OR:2.23,P<0.0001), alcohol consumption (OR:1.85,P=0.002) and co-morbidity (OR:0.21,P<0.00001) were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group (OR:0.21,P=0.001). More patients in the right-sided diverticulitis group had modified Hinchey stage I disease (OR:10.21,P<0.0001) while more patients in the left-sided group had stage II (OR:0.19,P<0.00001), stage III (OR:0.08,P=0.009) or stage IV disease (OR:0.02,P<0.00001). Right-sided diverticulitis was associated with a lower risk of recurrence (OR:0.49,P=0.04), failure of conservative management (OR:0.14,P=0.0006), the need for emergency surgery (OR:0.13,<0.00001) and shorter length of hospital stay (MD:-1.70,P=0.02). Conclusions Right-sided acute colonic diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence, and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Damage control strategy in perforated diverticulitis with generalized peritonitis

BackgroundThe best treatment for perforated colonic diverticulitis with generalized peritonitis is still under debate. Concurrent strategies are resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann’s procedure (HP), laparoscopic lavage (LL) and damage control surgery (DCS). This review intends to systematically analyze the current literature on DCS.MethodsDCS consists of two stages. Emergency surgery: limited resection of the diseased colon, oral and aboral closure, lavage, vacuum-assisted abdominal closure. Second look surgery after 24–48 h: definite reconstruction with colorectal anastomosis (−/ + DI) or HP after adequate resuscitation. The review was conducted in accordance to the PRISMA-P Statement. PubMed/MEDLINE, Cochrane central register of controlled trials (CENTRAL) and EMBASE were searched using the following term: (Damage control surgery) AND (Diverticulitis OR Diverticulum OR Peritonitis).ResultsEight retrospective studies including 256 patients met the inclusion criteria. No randomized trial was available. 67% of the included patients had purulent, 30% feculent peritonitis. In 3% Hinchey stage II diverticulitis was found. In 49% the Mannheim peritonitis index (MPI) was greater than 26. Colorectal anastomosis was constructed during the course of the second surgery in 73%. In 15% of the latter DI was applied. The remaining 27% received HP. Postoperative mortality was 9%, morbidity 31% respectively. The anastomotic leak rate was 13%. 55% of patients were discharged without a stoma.ConclusionDCS is a safe technique for the treatment of acute perforated diverticulitis with generalized peritonitis, allowing a high rate of colorectal anastomosis and stoma-free hospital discharge in more than half of the patients.

Routine colonoscopy may be needed for uncomplicated acute right colonic diverticulitis

BackgroundRoutine colonoscopy is recommended to determine the coexistence of colon cancer after medical treatment for colon diverticulitis. However, in the case of uncomplicated diverticulitis diagnosed by computed tomography, the clinical relevance of routine follow-up colonoscopy has recently been debated. Yet, the role of follow-up colonoscopy for right colon diverticulitis, which tends to develop at a younger age than left colon diverticulitis, has not been specifically evaluated. Therefore, we aimed to evaluate the incidence of right colon cancer or colonic adenomatous polyps, detected by routine colonoscopy, after conservative management of acute uncomplicated right colon diverticulitis.MethodsPatients with uncomplicated right colon diverticulitis (modified Hinchey stage Ia) diagnosed by computed tomography imaging, between 2011 and 2017, and who underwent follow-up colonoscopy surveillance after treatment were included. The primary outcome was the incidence of colon cancer, with the detection rate of adenoma being the secondary outcome. Information for analysis was retrieved retrospectively from patients’ medical records.Results The study group included 330 consecutive patients, with a mean age of 41.9 years, and 51.9% being men. For the primary outcome, the rate of colon cancer on follow-up colonoscopy was 0.3% (1/330 cases). The rate of adenoma detection was 20.9% (69/330 cases) and advanced adenoma (> 10 mm in diameter; or exhibiting a > 25% villous component or severe dysplasia), including colon cancer, was observed in 9 patients (2.7%).ConclusionsIn patients with acute uncomplicated right colonic diverticulitis, routine colonoscopy after conservative treatment may be necessary because although the colon cancer detection rate is low, it is possible to detect advanced colon adenoma.

A woman with abdominal pain while being treated with steroid

Introduction/Background Saccharomyces cerevisiae is a yeast of the phylum Ascomycota which can be used in food production. It has rarely been mentioned in the literature as a cause of human disease. Various types of infections have been reported, primarily bloodstream infections. Whether Saccharomyces is a cause of true infection in other sites as compared to a culture contaminant is controversial, as it is considered a normal part of the gastrointestinal (GI), vaginal, and respiratory mucosal flora. The main risk factors for infection with Saccharomyces are immunodeficiency including chemotherapy, history of a central venous catheter, gastroenterological surgery, and use of antibiotics or probiotics. We present the case of an 80-year-old woman who, after five days of dexamethasone treatment for COVID-19 pneumonia, presented with worsening abdominal pain. The patient was diagnosed with perforated diverticulitis, complicated by Saccharomyces cerevisiae fungemia. We will discuss the management of Saccharomyces cerevisiae fungemia and other infections to highlight the difficulty in management and high mortality risk associated with similar infections. Case Presentation An 80-year-old woman with no known medical history was admitted for COVID-19 pneumonia and hypoxia, for which she required four liters of oxygen. She was initially treated with dexamethasone, remdesivir, cefepime, and azithromycin. On the fifth day of hospitalization, she developed acute generalized abdominal pain. Computed tomography of the abdomen and pelvis (figure 2) showed pneumoperitoneum, sigmoid versus terminal ileum perforation, and two abscesses (measuring 5.5 cm and 8 cm in the largest diameters) in the pelvis. Surgical team recommended non-operative management. On days eight and ten of illness, blood cultures were obtained and grew Saccharomyces cerevisiae. Piperacillin-tazobactam was started for empiric GI coverage. Micafungin was started when yeast was identified in blood cultures and was subsequently switched to oral voriconazole once the yeast was identified as Saccharomyces. Blood cultures cleared four days after first positive. Due to persistently worsening leukocytosis, an exploratory laparotomy with sigmoidectomy and end colostomy was performed on day twelve of hospitalization. Intraoperative diagnosis of Hinchey stage IV diverticulitis (diverticulitis with generalized fecal peritonitis) was made. A drain was placed, and cultures from the abscess fluid grew Saccharomyces cerevisiae. In addition to the Saccharomyces isolate, a Mucor species grew in the abscess culture after four days, and the patient was transitioned to liposomal amphotericin B. Two days after amphotericin was started, the patient developed acute encephalopathy to the point where she was non-responsive to pain, believed to be secondary to amphotericin B neurotoxicity. She required transfer to a surgical intensive care unit. Liposomal amphotericin B was changed to intravenous posaconazole. Within 48 hours of stopping amphotericin, the patient's mental status showed moderate improvement and she was disoriented but conversive. She then developed refractory hypoxia and progressive kidney dysfunction, and ultimately required intubation and continuous renal replacement therapy. Surgical team questioned posaconazole as a cause for her worsening renal function, and she was subsequently switched to intravenous Isavuconazole. The patient continued to decline, requiring vasopressor support. She developed refractory metabolic acidosis and lactic acidosis, and hypoxia uncorrected with maximum ventilatory support. The patient's family requested to transition to comfort measures, and the patient expired on day 21 after initial COVID-19 admission. Discussion In one study, Saccharomyces cerevisiae was considered one of the nosocomially acquired infections. It has been reported to cause an average of 1.7% of all fungal cases. Our patient developed Saccharomyces cerevisiae after evidence of diverticulitis complicated by bowel perforation in the setting of being treated with broad-spectr m antibiotics and while not being known to use probiotics. Various types of GI infections have been reported in Saccharomyces cerevisiae, including esophagitis, peritonitis, liver abscess and a link to Crohn's disease, where antibodies to Saccharomyces cerevisiae are a sensitive and specific test. A key element in the management of Saccharomyces cerevisiae is the removal of the infected foreign bodies and the purification of the source. There are no guidelines for dealing with Saccharomyces cerevisiae infections, it is well known that it is susceptible to amphotericin B. Several different types of azole drugs have been investigated, resistance to itraconazole and fluconazole have been reported. Better susceptibility Results were observed with voriconazole and posaconazole. The mortality rate of Saccharomyces cerevisiae fungemia remains high and was reported in one study as 29.5%. Saccharomyces cerevisiae fungemia is a rare, lifethreatening disease with no clearly defined treatment guidelines. Further studies are needed to better understand the therapeutic antifungals options. (Table Presented).

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis

Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available. To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis. This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up. Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization. The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life. Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups. Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged. ClinicalTrials.gov Identifier: NCT01047462.

Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis.

The aim of this work was to compare demographic factors, outcomes and prognosis for right-sided versus left-sided acute colonic diverticulitis. We searched MEDLINE, CINAHL, EMBASE, CENTRAL, Scopus and unpublished literature to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis (PROSPERO registration number CRD42020180075). We used the QUIPS tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients [mean difference (MD) -14.16 (-17.19, -11.14), P<0.00001] and more male patients [odds ratio (OR) 1.33 (1.04, 1.71), P=0.02] compared with left-sided diverticulitis. Smoking [OR 2.23 (1.50, 3.32), P<0.0001], alcohol consumption [OR 1.85 (1.26, 2.71), P=0.002] and comorbidity [OR 0.21 (0.15, 0.30), P<0.00001] were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group [OR 0.21 (0.08, 0.55), P=0.001]. More patients in the right-sided diverticulitis group had modified Hinchey Stage I disease [OR 10.21 (3.34, 31.22), P<0.0001] while more patients in the left-sided group had Stage II [OR 0.19 (0.10, 0.38), P<0.00001], Stage III [OR 0.08 (0.01, 0.54), P=0.009] or Stage IV disease [OR 0.02 (0.00, 0.08), P<0.00001]. Right-sided diverticulitis was associated with a lower risk of recurrence [OR 0.49 (0.25, 0.98), P=0.04], failure of conservative management [OR 0.14 (0.04, 0.43), P=0.0006], the need for emergency surgery [OR 0.13 (0.05, 0.36), P<0.00001] and a shorter length of hospital stay [MD -1.70 (-3.08, -0.33), P=0.02]. Right-sided acute diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Difference in Clinical Features between Right- and Left-Sided Acute Colonic Diverticulitis

Right colonic diverticulitis (RCD) and left colonic diverticulitis (LCD) may have different clinical features due to the different embryologic origins and anatomical locations of each colon. Therefore, we aimed to compare RCD and LCD in terms of the associated clinical features. We retrospectively collected clinical data from patients who were diagnosed with acute colonic diverticulitis based on computed tomography findings between 2011 and 2017. RCD was defined as colonic diverticulitis extending from the caecum to the transverse colon, and LCD was defined as extending from the splenic flexure to the sigmoid colon. These analyses included 667 patients with RCD and 58 patients with LCD. Relative to the patients with LCD, the patients with RCD were younger (P < 0.001), were more likely to be male (P = 0.033), were taller (P < 0.001), had lower body mass index values (P < 0.001), had less advanced modified Hinchey stages (P < 0.001), and had shorter hospital stays (P < 0.001). Having LCD rather than RCD was a predictor of recurrent colonic diverticulitis (P = 0.003). Relative to LCD, RCD occurs at younger ages, is expressed at less advanced modified Hinchey stages, and is associated with lower risks of recurrence.

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy

IntroductionOver the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS.MethodsAll the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011–2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study.ResultsThere were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m2 (SD ± 3.33). Thirteen cases (38%) were Wasvary’s modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann’s procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann’s procedures.ConclusionDCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

Effectiveness of conservative approach in right colon diverticulitis.

Approximately 10%-25% of patients with colon diverticular disease experience colonic diverticulitis during their lives. Right-sided diverticulosis is a rare condition in Western countries, but it is common among Asian countries. The aim of this study was to evaluate the clinical and treatment outcomes in our patients with right colon diverticulitis. Demographic and clinical data of 22 patients with a diagnosis of cecum and right-sided colon diverticulitis between 2014 and 2017 were analyzed. The Hinchey staging was applied according to the radiological evaluation and clinical findings. Then, the proportions of demographic and clinical features of the patients according to the Hinchey staging and its statistical significance were evaluated. Our study included 22 patients who suffered from right colon diverticulitis. The female-to-male ratio was 0.69. A total of 68.1% of the patients were the Hinchey Stage I, and 31.8% were the Hinchey Stage II, all of which were evaluated by tomography. The Hinchey Stage I diverticulitis was mostly found in the right colon (66.7%) and the Hinchey Stage II diverticulitis in the cecum (57.1%). The mean age of the Hinchey Stage II patients was higher (63.6 years) and statistically significant (p<0.05). Two patients had appendectomy, and one had right hemicolectomy. Conservative treatment was applied to other 19 patients. The mean hospitalization time was 3.4 days. Four patients who received conservative treatment at the 2-year follow-up had recurrence. No recurrence was observed in patients receiving surgical treatment. Right colon diverticulitis is usually seen in solitary men aged <50 years from Eastern societies. As a treatment option, conservative methods should be preferred, especially in uncomplicated cases. Surgical treatment is usually used in the treatment of recurrent and complicated cases.

Suitability of Primary Anastomosis for Colorectal Perforation

Colorectal perforation is often treated with colostomy without primary anastomosis due to the risk of anastomotic leakage. However, colostomy affects the patients’ quality of life and may cause complications during closure. This study aimed to examine the suitability of primary anastomosis for colorectal perforation and determine the risk factors for postoperative anastomotic leakage. We retrospectively examined patients who underwent emergency surgery for colorectal perforation associated with generalized peritonitis between April 2007 and March 2017. Cases with iatrogenic or traumatic causes were excluded. Patients were divided into primary anastomosis and colostomy groups. Their age, time after onset, preoperative sequential organ failure assessment (SOFA) score, perforation site, cause of perforation, shock, intraperitoneal infection, steroid use, chronic renal failure, and mortality were compared. Subgroup analysis of the primary anastomosis group was performed to identify risk factors for anastomotic leakage. The cohort comprised 232 patients (112 men, 120 women; mean age, 73 years). Primary anastomosis and colostomy were performed in 27 and 205 patients, respectively. The primary anastomosis group consisted mainly of men with right colonic perforation. Of the 27 patients who underwent primary anastomosis, anastomotic leakage occurred in 5 (18.5%). Patients with anastomotic leakage demonstrated high SOFA scores (4.2 vs. 1.9, p < 0.05) and Hinchey stage IV disease (80% vs. 27.3%, p < 0.05). Of the 5 patients with anastomotic leakage, 2 died. Anastomotic leakage after primary anastomosis for colorectal perforation occurs in patients with septic complications or severe intraperitoneal infection. Therefore, primary anastomosis should be avoided in this patient population.