Perforated Diverticulitis Research Articles

What is the current role of laparoscopic lavage in perforated diverticulitis?

Patients with perforated diverticulitis suffer high morbidity and mortality. For decades, sigmoid colectomy with colostomy (Hartman’s procedure) has been considered the standard surgical management. Over the past several years, less-morbid alternatives have been advocated. Laparoscopic lavage showed promise in retrospective studies. However, recent prospective randomized clinical trials have suggested that outcomes may not be better compared with the Hartman’s procedure. A critical analysis of the literature leads the authors to the conclusion that there is still a role for laparoscopic lavage in selected patients, as a bridge to elective colectomy or, in some cases, as definitive management.

Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air.

Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has a success rate of 40-70%. Identifying patients with a risk of medical treatment failure would improve outcomes. The aim of this study was to identify the risk factors for failure of medical treatment in patients admitted with PDwAP. This multicenter retrospective observational study included all consecutive patients admitted for PDwAP and not surgically treated over a 7-year period. Peritonitis classified on the Hinchey scale was excluded. Potential clinical, biological and radiological risk factors for medical treatment failure were collected and compared between the group of patient with a failure of medical treatment (F) and the group in which treatment did not fail. Data were collected at referral. Ninety-one patients were included, and 29 had a failure of treatment (31.9%). The median heart rate was different between the two groups (p<0.001), at approximately 100/min in the F group. A blood level of C-reactive protein (CRP) ≥150mg/mL was associated with a higher rate of failure (p=0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5mm and intraperitoneal liquid located in the pouch of Douglas were more likely to be present in the F group (respectively, p=0.001 and p<0.001). A multivariate analysis showed independent risk factors as being the highest pneumoperitoneum diameter >5mm (OR 5.193; p=0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p=0.036). The severity of sepsis (tachycardia and CRP ≥150mg/mL) and of imaging signs (pneumoperitoneum ≥5mm and peritoneal fluid in the pouch of Douglas) were risk factors for medical treatment failure of PDwAP requiring special supervision so as not to lose time in undertaking surgical management.

Perforation of Meckel's Diverticulum by a Fish Bone Presenting as Acute Appendicitis: A Case Report

Meckel's diverticulum can present with unusual symptoms and signs leading to delay diagnosis. Herein, we report a case of a 48-year-old Chinese man who presented to us for symptom of acute appendicitis. Further investigation by computed tomography scan pelvis showed acutely inflamed medium sized diverticulum at the distal ileum with focal perforation and peritonitis. Laparoscopy showed perforated meckel's diverticulitis with a fish bone half perforated out and localised abscess formation. He had unremarkable post-operative course. We review the literature about complication of Meckel's diverticulum and the necesssity of surgical removal.

Response to Re: Treat the patient or radiology? Free intraperitoneal gas in clinically well patients with perforated diverticulitis

Response to Re: Treat the patient or radiology? Free intraperitoneal gas in clinically well patients with perforated diverticulitis

Attempted Colonic Preservation Strategies Do Not Increase the Risk of In-Hospital Mortality in Patients Presenting with Acute Left-Sided Colonic Emergencies

Background. Colonic malignant obstruction and perforated diverticulitis are acute left sided colonic emergencies (ALSCE) that are typically managed with colorectal resection. Colonic preservation techniques such as laparoscopic lavage and endoscopic stenting have emerged as management options, the safety of which has been debated. We aimed to determine if these alternate colonic preservation techniques result in increased in-hospital mortality. Materials and Methods. Retrospective analysis of prospectively collected data of 210 patients with ALSCE managed from June 2001 to April 2014. Data collected included demographic, pathology type, ASA grading, operative and post-operative progress. Univariable and multivariable logistic regression was performed to determine factors contributing to treatment arm allocation and in-hospital mortality. These were performed on the whole treatment cohort, as well as per pathology subgroup. Results. 210 patients were included. Non-resectional management was attempted in 147 patients (70%), of which 38 (26%) required un-planned colonic resection or died in hospital. Those treated with colonic preservation were younger, had lower ASA scores and had lower Hinchey scores (in the diverticular perforation group) than those in the resection group. Female gender was the only independent predictor of increased in-hospital mortality risk. Importantly, the type of procedure performed (colonic preservation vs. resection) did not predict in-hospital mortality risk. Conclusion. Attempted colonic preservation strategies do not increase the risk of in-hospital mortality in patients presenting with ALSCE. Given the inherent benefits of colonic preservation, these treatment strategies should be considered when managing ALSCE.

Synchronous acute appendicitis, perforated caecal diverticulitis and serrated adenoma of right-sided colon: An uncommon incidental finding

Synchronous acute appendicitis, perforated caecal diverticulitis and serrated adenoma of right-sided colon: An uncommon incidental finding

治療に難渋した慢性結腸憩室炎の1例

A 73-year-old woman with a history of perforated diverticulitis in the sigmoid colon and chronic kidney disease was brought to our hospital with acute left lower abdominal pain. Abdominal computed tomography showed descending colitis. Contrast enema and colonoscopy revealed that the entire circumference of the descending colon was constricted. Abdominal angiography showed obstruction at the root of the inferior mesenteric artery. The patient was diagnosed with chronic ischemic changes combined with chronic diverticulitis. Proctosigmoidectomy (Hartmann procedure) was performed, and the postoperative course was uneventful. The patient has experienced no recurrence or complications to date.

Cost analysis of laparoscopic lavage compared with sigmoid resection for perforated diverticulitis in the Ladies trial.

BackgroundLaparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study.MethodsThis study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention‐to‐treat) for up to 1 year after randomization.ResultsEighty‐eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € − 3512, 95 per cent bias‐corrected and accelerated c.i. −16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € − 2509 to −4438).ConclusionLaparoscopic lavage for perforated diverticulitis is more cost‐effective than sigmoid resection.

Laparoscopically Assisted Reversal of Hartmann's Procedure for Perforated Diverticulitis

The aim of this study was to retrospectively review the clinical outcomes of laparoscopically assisted and open surgical reversal of Hartmann's procedure (HR). We reviewed all patients undergoing laparoscopic or open HR at Tri-Service General Hospital, Taipei, Taiwan, between January 2002 and January 2010. A total of 34 perforated diverticulitis patients initially treated by exploratory laparotomy with Hartmann's procedure were enrolled and divided into 2 groups: laparoscopic and open HR. Data relative to patient age at the time of HR, sex, body mass index, operative time, longest incision length, estimated blood loss, intraoperative complications, postoperative complications, time to bowel function return, duration of hospitalization, and length of follow-up were reviewed. The median colostomy closure period was significantly higher in the laparoscopic group than in the open group (P = 0.011). The median longest incision length, estimated blood loss, time to first oral intake, and hospital stay were significantly lower in the laparoscopic group compared with the open group. Laparoscopic HR may be a technically safe, feasible approach that provides better cosmesis, less blood loss, and faster recovery compared with open HR.

Masquerading as Malignancy: A Case of a Misleading Gallbladder Abscess

Introduction: A gallbladder mass should always concern a clinician for malignancy. However, clinical and radiologic data are surprisingly similar for benign and malignant disease. A few cases of gallbladder abscesses mimicking cancer have been described in the setting of cholecystitis or as a complication of spilled gallstones after laparoscopic cholecystectomy. Our case is unique, as our patient had no known risk factors for abscess formation. Case: A 64-year old male presented with intermittent abdominal pain and fevers, night sweats, and 30-pound weight loss over 2 months. Physical exam was unremarkable. Lab studies showed mild leukocytosis with WBC 13.6 and normal LFTs. CT scan revealed a gallbladder mass with pneumobilia. MRI showed a diffusely thickened gallbladder with fistulization to the transverse colon, suspicious for malignancy. CA-19-9 was normal. PET-CT depicted increased uptake in the area of the gallbladder and hepatic flexure. Pre-operative diagnosis of gallbladder cancer was made and a radical en bloc cholecystectomy with partial hepatectomy and partial transverse colectomy was performed. Post-operative pathology revealed no malignancy, but rather an abscess involving the liver, gallbladder, and colon. Discussion: Diagnosis of gallbladder pathology is challenging due to nonspecific clinical and radiologic findings. The four distinct radiologic patterns are polypoid gallbladder mass, focal or diffuse gallbladder wall thickening, polypoid bile duct mass, and focal bile duct stricture. These can occur with benign or malignant lesions. Specificity of US, CT and MRI to distinguish benign from malignant gallbladder lesions is poor. Additionally, PET yields false positives in inflammation. Known masqueraders in the gallbladder are adenomyomatosis, xanthogranulomatous cholecystitis, and tuberculoid granulomatosis. Our patient had an intact gallbladder with no signs of cholelithiasis, cholecystitis, or other chronic process. Further review of his case revealed hepatic flexure diverticula on CT and foreign body giant cells in the abscess on pathology suggesting a possible perforated diverticulitis with fistulization to the gallbladder as the etiology of our patient's abscess. The best means of accurately diagnosing gallbladder pathology remains to be determined. Clinicians must beware of radiologic limitations and hold a high index of suspicion for malignancy in the right clinical context, but be mindful of mimicry as well.Figure 1Figure 2

Laparoscopic peritoneal lavage for perforated diverticulitis: are we any further forward?

Laparoscopic peritoneal lavage for perforated diverticulitis: are we any further forward?

Management of Diverticular Disease in Scandinavia.

Throughout the last century, the incidence of diverticular disease of the colon has increased tremendously in industrialized countries; nevertheless, the management of this condition is still controversial. Although several international guidelines for the management of diverticular disease are based on the same evidence, the recommendations differ greatly, emphasizing the lack of high-quality prospective studies. In Scandinavia, official guidelines for the management of diverticular disease exist only in Denmark. However, the treatment policies are quite similar in all Scandinavian countries. Computed tomography is the first choice for imaging of acute diverticulitis and its complications. Furthermore, the use of antibiotics in uncomplicated diverticulitis is nearly abandoned in Scandinavia, whereas several international guidelines still recommend their use. There is a broad consensus that abscesses secondary to acute diverticulitis can safely be managed with percutaneous drainage, which is in line with international recommendations. The surgical management of perforated diverticulitis with peritonitis is still as controversial in Scandinavia as elsewhere. Common surgical options are laparoscopic peritoneal lavage, primary resection with anastomosis, and primary resection with terminal colostomy (Hartmann's procedure). Elective sigmoid resection in patients with diverticular disease seems to be performed less frequently in Scandinavia than in other European countries; the right indications are a current matter of debate. Symptomatic uncomplicated diverticular disease in the absence of diverticulitis has not gained great attention in Scandinavia.

Acute Perforating Diverticulitis Associated with Active Ulcerative Colitis: Yes, It Does Occur

A 79-year-old female with a past medical history of UC presented with persistent watery diarrhea, abdominal pain, nausea, vomiting, and low-grade fever. She had originally presented 1.5 years prior with persistent hematochezia prompting colonoscopy which revealed congestion, erosions, erythema, friability, granularity and loss of vascularity extending in a continuous and circumferential pattern from the anus to the sigmoid colon. Numerous small and large-mouthed diverticula were found in the sigmoid colon and in the descending colon. Rectosigmoid biopsy revealed crypt distortion with increased lymphoplasmacytic and neutrophilic inflammatory infiltrate in the lamina propria and associated cryptitis, crypt abscesses, and reactive epithelial cell changes consistent with a diagnosis of UC. Over the next 1.5 years she intermittently tolerated combinations of 5-aminosalicylic acid preparations (5-ASA) and steroid suppositories and enemas with concomitant oral 5-ASA therapies. However she eventually developed steroid-dependent UC. Given persistent side effects of chronic steroid therapy biologic therapy with infliximab was started approximately one week prior to presentation. On admission to hospital, she was started on broad-spectrum antibiotics and intravenous steroids. With a negative infectious workup, she was continued on an accelerated infliximab program. This was complicated by the development of Clostridium Difficile colitis, requiring oral vancomycin therapy. She subsequently developed worsening abdominal pain prompting computed-tomography evaluation which revealed colitis with increased wall thickening and pericolonic inflammation along the descending colon with an associated droplet of extraluminal air and rim-enhancing fluid in the left paracolic gutter compatible with perforation. She underwent emergent exploratory laparotomy with identification of a descending colonic perforation resulting in subtotal colectomy with end ileostomy. Her post-op course was complicated by multiple pelvic fluid collections documented on serial imaging requiring drainage and growth of Vancomycin-Resistant Enteroccocus. Microscopic surgical pathology showed chronic UC associated with extensive colonic diverticulosis with acute perforative diverticulitis, subserosal abscesses and acute purulent serositis. The inflammation of UC was limited to the deep submucosa. There was no dysplasia, granulomata, or viral inclusions present.

Long-term follow-up of lung transplant recipients supports non-operative treatment of uncomplicated diverticulitis.

We aim to assess the incidence, current treatment, and outcome of diverticulitis in highly immunosuppressed lung transplant recipients. Retrospective analysis of a prospective database of 403 lung transplant recipients transplanted between 1992 and 2013 with a mean follow-up of 100months (SD 58.0). 4.46% of lung transplant recipients (n=18) developed diverticulitis. Eight lung transplant recipients developed uncomplicated diverticulitis, which were all treated successfully with antibiotics. Three patients (37.5%) underwent elective sigmoid resection with severe Grade 3b complications after two of five (40%) surgical procedures. Diverticulitis recurrence occurred in five patients (60%). In total, 10 lung transplant recipients presented with 11 episodes of perforated diverticulitis with a 30-day mortality rate of 9.1%. Hartmann procedure was performed in eight lung transplant recipients. Sigmoid resection with primary anastomosis and protective ileostomy was performed in three patients with Hinchey I. Two of these patients developed anastomotic leakage with a secondary Hartmann procedure. Due to high leakage rate after resection with primary anastomosis and protective ileostomy in our cohort of lung transplant recipients with perforated diverticulitis, the Hartmann procedure seems to be the safer option. In contrast, in uncomplicated diverticulitis, non-operative treatment can be considered as a safe and highly successful treatment option, even for recurrences.

Treat the patient or radiology? Free intraperitoneal gas in clinically well patients with perforated diverticulitis.

Treat the patient or radiology? Free intraperitoneal gas in clinically well patients with perforated diverticulitis.

Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials.

ObjectivePurulent peritonitis from acute left colon diverticulitis is a relatively common presentation of diverticular disease; historically the treatment was the Hartmann procedure. Laparoscopic peritoneal lavage has been proposed as a lesser invasive treatment option with great interest and debate among surgeons and with contrasting results. The aim of this meta-analysis was to compare the results of sigmoid resection with laparoscopic lavage.MethodsA systematic review was performed to select randomized controlled trials comparing laparoscopic lavage versus resection in Hinchey III diverticulitis. Studies’ selection, data extraction and risk of bias assessment were done by two independent authors; results were shown as OR with 95 % C.I.ResultsThree RCT were selected for the meta-analysis including 315 patents. Laparoscopic lavage was associated with significantly more reoperations (OR 3.75, p = 0.006) and more intra-abdominal abscesses (OR 3.50, p = 0.0003) with no differences in mortality (OR 0.93, p = 0.92). At 12 months follow up laparoscopic lavage was associated with lesser reoperations (OR 0.32, p = 0.0004); there were no differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR 0.74 p = 0.51).ConclusionsThe present meta-analysis shows that in acute perforated diverticulitis with purulent peritonitis laparoscopic lavage is comparable to sigmoid resection in term of mortality but it is associated with a significantly higher rate of reoperations and a higher rate of intra-abdominal abscess. No differences in term of mortality were demonstrated at follow-up. Further studies are needed to better define the safety and appropriateness of this treatment.

Diverticulitis in immunosuppressed patients: Afatal outcome requiring a new approach?

Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes. This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated. Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis. Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.

The Clinical Challenges of Necrotizing Fasciitis.

Necrotizing fasciitis (NF) is a rare, rapidly spreading infection of the subcutaneous tissue that can lead to life- and/or limb-threatening systemic toxicity. The etiology is usually polymicrobial, but single-species organisms (usually streptococcal or staphylococcal) are isolated in about one-third of cases. Despite its relative rarity, many medical specialists, including orthopaedists, can expect to see at least 1 case of NF in their career. Early cutaneous signs (erythema, edema, and occasionally crepitus) are nonspecific, but because the infection spreads so rapidly, prompt diagnosis and early treatment are of paramount importance. This month’s “Case Connections” springboards from a case report about necrotizing fasciitis in which the infectious source was highly unusual. In the June 8, 2016, edition of JBJS Case Connector, Connor et al. reported on the case of a 70-year-old man who developed necrotizing fasciitis of the thigh and calf following sigmoid diverticulitis perforation. The patient presented with fever and acute-onset left calf and knee pain of 3 days’ duration. He had no history of diverticular disease, surgery, blunt trauma, or penetrating injury to the affected limb. Lab results indicated the presence of systemic infection and inflammation, and radiography and ultrasound revealed subcutaneous and intramuscular gas in the lower leg (Fig. 1) and thigh. Doctors presumptively diagnosed necrotizing fasciitis and began intravenous antibiotics. On the day of admission, surgeons performed extensive skin and subcutaneous tissue debridement and irrigation in all of the affected compartments. Fig. 1 Radiograph of the tibia and fibula showing subcutaneous and intramuscular gas. These findings led surgeons to presumptively diagnose necrotizing fasciitis. Shortly thereafter, a CT scan of the abdomen revealed sigmoid diverticulitis with a perforation that communicated with the left hip via the iliopsoas fascia. Surgeons performed a sigmoid colectomy and transverse loop colostomy, and the antibiotic regimen was adjusted to cover the pseudomonal organisms that were …

Necrotizing Fasciitis of the Thigh and Calf: A Reminder to Exclude a Perforated Intra-Abdominal Viscus: A Case Report.

Diverticular disease and its associated complications are an increasing problem among Western populations. Perforated diverticulitis results in intra-abdominal sepsis, which rarely causes a life-threatening necrotizing soft-tissue infection. We present the case of a 70-year-old man with a sigmoid diverticulitis perforation presenting as necrotizing fasciitis of the thigh and calf requiring serial debridement and major limb reconstruction. Clinicians should be aware of index presentations of diverticulitis and its recognized complications in this demographic group. For the orthopaedic and the general surgeon, knowledge of the dangers of the concomitant presence of these 2 conditions will substantially reduce morbidity and mortality.

Contemporary Review of Risk‐Stratified Management in Acute Uncomplicated and Complicated Diverticulitis

Acute colonic diverticulitis is a common clinical condition. Severity of the disease is based on clinical, laboratory, and radiological investigations and dictates the need for medical or surgical intervention. Recent clinical trials have improved the understanding of the natural history of the disease resulting in new approaches to and better evidence for the management of acute diverticulitis. We searched the Cochrane Library (years 2004-2015), MEDLINE (years 2004-2015), and EMBASE (years 2004-2015) databases. We used the search terms "diverticulitis, colonic" or "acute diverticulitis" or "divertic*" in combination with the terms "management," "antibiotics," "non-operative," or "surgery." Registers for clinical trials (such as the WHO registry and the https://clinicaltrials.gov/ ) were searched for ongoing, recruiting, or closed trials not yet published. Antibiotic treatment can be avoided in simple, non-complicated diverticulitis and outpatient management is safe. The management of complicated disease, ranging from a localized abscess to perforation with diffuse peritonitis, has changed towards either percutaneous or minimally invasive approaches in selected cases. The role of laparoscopic lavage without resection in perforated non-fecal diverticulitis is still debated; however, recent evidence from two randomised controlled trials has found a higher re-intervention in this group of patients. A shift in management has occurred towards conservative management in acute uncomplicated disease. Those with uncomplicated acute diverticulitis may be treated without antibiotics. For complicated diverticulitis with purulent peritonitis, the use of peritoneal lavage appears to be non-superior to resection.