Management Of Complicated Diverticulitis Research Articles

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly.

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65–74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65–92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1–48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort

Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Undergoing HP vs PAPD. Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11 514 patients [35.6%]; P < .001). In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30 851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). This study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with patients who underwent HP. These findings suggest that further delineation of criteria for appropriate application of PAPD in the urgent setting are warranted.

EP.FRI.1040 Management of Acute Colonic Diverticulitis According to The WSES (World Society of Emergency Surgery) Classification in a Tertiary Centre

Abstract Aims Debate remains regarding management of complicated diverticulitis. The WSES acute diverticulitis working group published in 2015 a CT-guided classification of left colon acute diverticulitis, divided into uncomplicated (Stage 0) and complicated (Stage 1a-4). Using this classification, we reviewed our management of CT-proven acute colonic diverticulitis. Methods A single-centre retrospective review of management of CT-proven acute colonic diverticulitis over 12 months based on the WSES classification. Results 24 males and 31 females presented (median age=56, IQR 45-68). Median white cell count=12 (IQR 10-16) and median C-reactive protein=88 (IQR 41-157). Based on CT, 25 (45.5%) patients =stage 0, 14 (25.5%) =stage 1a, 6 (11%) =stage 1b, 4 (7%) =stage 2a, 6 (11%) =stage 2b, and none staged 3/4. 15% (8/55) patients had an operation, remainder were conservatively managed. 2 patients had laparoscopic washout/drainage (stages 1b and 2b). 6 patients had Hartmanns (x1 stage 1a, x1 stage 1b, x4 stage 2b). Median length of stay=5 days (IQR 4-8). There was 1 related reattendance declining readmission (stage 1a managed conservatively) and 2 readmissions (1 stage 0 managed conservatively, other initially stage 1a managed conservatively but on readmission staged 2b proceeding to Hartmanns). 30-day mortality included 3 deaths (stages 1b/2a/2b all managed conservatively). Conclusions Hartmanns resection is advocated as treatment of choice for complicated acute diverticulitis, particularly for Stage 2b or above.

Minimally Invasive Management of Complicated Diverticular Disease: Current Status and Review of Literature.

Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical management of diverticulitis has undergone significant changes in recent years. This article reviews the role of minimally invasive approach in management of complicated diverticulitis, with a focus on recent concepts and advances. A literature review of past 10 years (January 2004 to September 2014) was performed using the electronic database MEDLINE from PubMed which included articles only in English. We identified total of 139 articles, out of which 50 were excluded resulting in 89 full-text articles for review 16 retrospective studies, 7 prospective cohorts, 1 case-control series and 1 systematic review were included. These suggest that urgent surgery is performed for those with sepsis and diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage. In addition, 3 randomized control trials: DILALA, LapLAND and the Scandinavian Diverticulitis trial are working towards evaluating whether laparoscopic lavage is safe in management of complicated diverticular diseases. Growing trend toward conservative or minimally invasive treatment modality even in severe acute diverticulitis was noticed. Laparoscopic peritoneal lavage has evolved as a good alternative to invasive surgery, yet clear indications for its role in the management of complicated diverticulitis need to be established. Recent evidence suggests that existing guidelines for optimal management of complicated diverticulitis should be updated. Non-resectional radiographic techniques are likely to play a prominent role in the initial treatment of complicated diverticulitis in the near future.

Laparoscopic Lavage and Drainage in the Management of Complicated Diverticulitis: Review of the Literature

Introduction: Diverticular disease affects more than 60% of adults aged older than 70. The lifetime prevalence of diverticulitis is 4%-25%, 20% of which will experience severe complications, and 1% will require emergent surgery. We review the most relevant literature regarding the management of complicated acute diverticulitis with laparoscopic lavage and drainage (LLD). Discussion: Hartmann Procedure (HP) is considered the current gold standard for treating complicated diverticulitis; it is associated with a high mortality and morbidity. LLD is reported to improve outcomes. In addition, it may act either as a definitive procedure or as a bridge and allow for a latter elective sigmoidectomy. There is only one preliminary report of a prospective randomized trial regarding this matter (DILALA trial) which fails to demonstrate decreased morbidity and mortality between LLD vs. HP.

Nonoperative Management of Complicated Diverticulitis with Extradigestive Air

Nonoperative Management of Complicated Diverticulitis with Extradigestive Air

Corman’s Colon and Rectal Surgery, 6th edition

International collaboration between surgeons with different backgrounds, practicing in different healthcare systems, has always spurred advances in our knowledge of colorectal disease and improvements in colorectal surgery standards. Today, like never before, the colorectal surgery community has gone global and the benefits of these collaborations are extended to every surgeon practicing our specialty. This is reflected in the sixth edition of Corman’s Colon and Rectal Surgery where Dr. Corman invited surgeons who have an international outlook such as Roberto Bergamaschi, Victor Fazio, and John Nicholls to contribute as co-editors. Most chapters have been thoroughly updated to reflect the technical advances, and the new literature that has appeared since the last edition of 2004, while other chapters have been completely rewritten. The chapter on laparoscopic colorectal surgery, rewritten by Dr. Bergamaschi, contains an in-depth discussion of every aspect of laparoscopic colorectal surgery including some that are rarely found in books such as learning and simulation. The operating room descriptions are so exact, precise, and thorough that it feels like being there. The technical explanation touches on the most salient points of each procedure with a very experienced perspective and very rich details for a textbook. The parts on robotics and on transanal minimally invasive surgery are very current. A notable omission was the HALS approach to minimally invasive surgery, widely practiced throughout the world and just as difficult and challenging as the ‘‘pure laparoscopic’’ approach favored by the authors. John Nicholls has rewritten the chapters on fecal incontinence and constipation. The evaluation of fecal incontinence includes a discussion on MRI and 3D US. All modalities of treatment, particularly sacral neuromodulation which has been practiced in Europe for almost 10 years, are discussed and evaluated with a systematic approach and a deep personal understanding. The chapter on constipation is well organized and gives incredible insight into the management of this difficult patient population. Also the chapter on today’s management of complicated diverticulitis was rewritten by Nicholls in a methodical and clinically exceptional fashion. Among the chapters that were thoroughly updated a particular mention goes to the one by Dr. Corman on hemorrhoids. This chapter is a ‘‘classic,’’ with its in-depth discussion of the multiple modalities of therapy according to the multiple clinical presentations of this disease. Just recently, after this book was published, Ethicon has decided to withdraw the PPH stapler from the US market, while a slightly different Covidien stapler is still available to the American surgeons who use this technique. Finally, while turning the pages, one cannot help gazing at the profiles of people who made a significant contribution to our specialty and be inspired by their gestes. As in the previous editions, Dr. Corman’s knowledge, wisdom, and experience permeates this textbook and guides the new generation of colorectal surgeons. He not only provides an enjoyable learning experience but also exhorts us to think and to critically appraise the enormous amount of information available to us.

Surgery for Complicated Diverticulitis

Management of complicated diverticulitis continues to evolve. The dogma of decades past has undergone reevaluation in the wake of modern techniques and critical care management. This article attempts to address the following questions: (1) what defines “complicated diverticulitis”; (2) when is an intervention beyond medical management indicated; and (3) what currently (based on the type of complication) appears to be the optimal intervention?

The Management of Complicated Diverticulitis and the Role of Computed Tomography

Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Surgical management of complicated diverticulitis.

THE morbidity associated with the surgical treatment of diverticulitis remains high. In the experience of the Lahey Clinic some complication has developed in 30 per cent of the patients with diverticulitis — obstruction or perforation of the colon, or a fistula between the colon and bladder, or colon and vagina. When these complications do occur, a long period in the hospital, multiple operations and months of disability are all too frequently the result. There are two ways in which this situation can and should be improved. In the first place, one must avoid inadequate surgical procedures in patients with complicated . . .