Surgical Management Of Acute Diverticulitis Research Articles

Acute diverticulitis: Surgical management

The management of acute diverticulitis is a constantly evolving field. Diverticular disease can range from mild abdominal pain to severe disease with perforation and sepsis. Due to this wide spectrum of presentation, management must be tailored to the individual. Treatment options vary from medical management to laparoscopic lavage to colectomy to appropriately treat the patient. The surgeon is responsible in assessing the necessity of surgery for patients who not only present acutely, but for those who have recovered and may need planning for possible recurrences. This chapter will review the current recommendations for the surgical management of acute diverticulitis.

Validation of the Adapted Clavien-Dindo in Trauma (ACDiT) Classifications in Medical and Surgical Management of Acute Diverticulitis.

To validate the adapted Clavien-Dindo in trauma (ACDiT) tool as a novel outcome measure for patients with acute diverticulitis managed both operatively and nonoperatively. Complications following diverticulitis are difficult to classify because no traditional tools address patients managed both operatively and nonoperatively. The ACDiT grading system-graded from 0 to 5b-is applied in this manner but has not yet been validated for this patient group. We performed a 5-year observational study of patients with acute diverticulitis at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT scores were assigned, and validation was undertaken by comparing scores with hospital-free days, and verifying that higher scores were associated with known risk factors for poor outcomes. Inverse probability weighted propensity scores were assigned for surgical management, and inverse probability weighted regression analysis was used to determine factors associated with ACDiT ≥ grade 2. Of 260 patients, 188 (72%) were managed nonoperatively. Eighty (31%) developed a complication; 73 (91%) were grades 1 to 3b. Higher grades correlated inversely with hospital-free days (rs = -0.67, P < 0.0001) for all patients and for nonoperative (rs = -0.63, P < 0.0001) and operative (rs = -0.62, P < 0.0001) patients. Hinchey 2 to 3 and initial operative management had higher odds of having a complication of ACDiT ≥ grade 2. The ACDiT tool was successfully applied to acute diverticulitis patients managed operatively and nonoperatively, is associated with known risk factors for adverse outcomes. ACDiT may be considered a meaningful outcome measure for comparing strategies for acute diverticulitis.

Emergency Surgery in Acute Diverticulitis: A Systematic Review.

Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis. The aim of this systematic review was to define the accurate surgical management of acute diverticulitis. Medline, Embase, and the Cochrane Library were sources used. One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee. The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach. Morbidity, mortality, long-term stoma rates, and quality of life were measured. Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach. Trials specifically assessing Hinchey IV diverticulitis have not yet been completed. High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

Hartmann's Procedure vs Primary Anastomosis with Diverting Loop Ileostomy for Acute Diverticulitis: Nationwide Analysis of 2,729 Emergency Surgery Patients

Recent small randomized trials suggest that primary anastomosis with a diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for patients with acute diverticulitis necessitating emergent operation. We sought to examine the 30-day outcomes of patients undergoing emergent HP vs PADLI. Using the American College of Surgeons NSQIP Colectomy Procedure Targeted Database from 2012 to 2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity, and individual postoperative complications (eg surgical site infection, bleeding, sepsis) of the 2 procedures, controlling for all preoperative variables (eg demographics, comorbidities, laboratory values, illness severity), as well as intraoperative and procedure-specific variables (eg wound classification). Of 130,963 patients, 2,729 patients were included. Median age was 64 years, 48.5% were male; the majority of patients underwent HP and only 208 (7.6%) underwent PADLI. Hartmann's procedure patients had more comorbidities (eg COPD: 9.8% vs 4.8%; p= 0.017), were more functionally dependent (6.3% vs 2.4%; p= 0.025), and were sicker (eg septic shock: 11.1% vs 5.3%; p= 0.015) compared with PADLI patients. The mortality rates for HP vs PADLI were 7.6% and 2.9%, respectively (p= 0.011). The morbidity rates were 55.4% and 48.6%, respectively (p= 0.056). In multivariable analyses, compared with HP, PADLI did not result in increased rates of mortality (odds ratio 0.21; 95% CI 0.03 to 1.58; p= 0.129) or morbidity (odds ratio 0.96; 95% CI 0.63 to 1.45; p= 0.834). The odds of most major postoperative complications were also similar for HP and PADLI overall. Currently, surgeons perform HP more frequently than PADLI. When controlling for patient population differences, PADLI appears to be at least a safe alternative to HP for select patient populations needing emergent surgical management of acute diverticulitis.

Impact of CT imaging on predicting the surgical management of acute diverticulitis.

PurposeThe incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment.MethodsThree hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index.ResultsAfter propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively).ConclusionThis study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Post-operative morbidity, but not mortality, is worsened by operative delay in septic diverticulitis.

Optimal timing of surgery for acute diverticulitis remains unclear. A non-operative approach followed by elective surgery 6-week post-resolution is favored. However, a subset of patients fail on the non-operative management during index admission. Here, we examine patients requiring emergent operation to evaluate the effect of surgical delay on patient outcomes. Patients undergoing emergent operative intervention for acute diverticulitis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Primary endpoints of 30-day overall morbidity and mortality were evaluated via univariate and multivariate analysis. Of the 2,119 patients identified for study inclusion, 57.2% (n=1212) underwent emergent operative intervention within 24h, 26.3% (n=558) between days 1-3, 12.9% (n=273) between days 3-7, and 3.6% (n=76) greater than 7days from admission. End colostomy was performed in 77.4% (n=1,640) of cases. Unadjusted age and presence of major comorbidities increased with operative delay. Further, unadjusted 30-day overall morbidity, mortality, septic complications, and post-operative length of stay increased significantly with operative delay. On multivariate analysis, operative delay was not associated with increased 30-day mortality but was associated with increased 30-day overall morbidity. Hartmann's procedure has remained the standard operation in emergent surgical management of acute diverticulitis. Delay in definitive surgical therapy greater than 24h from admission is associated with higher rates of morbidity and protracted post-operative length of stay, but there is no increase in 30-day mortality. Prospective study is necessary to further answer the question of surgical timing in acute diverticulitis.

Emergency surgery for acute diverticulitis

The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann's procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38-1.56; p = 0.465), 0.47 (95% CI, 0.06-3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19-13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. Therapeutic study, level IV.

Drenaje laparoscópico de Ia diverticulitis aguda complicada Hinchey II y III

Laparoscopic peritoneal lavage for acute diverticulitis Background: The usual surgical management of acute diverticulitis is Hartmann operation that is asso- ciated with high rates of complications and mortality. Recently, less invasive procedures, that avoid ostomies have been proposed as treatment. Aim: To analyze the results of laparoscopic peritoneal lavage in patients with acute diverticulitis. Material and Methods: Prospective analysis of seven patients age 25 to 61 years (four males) admitted for a first episode of acute diverticulitis classified as Hinchey II or III, in whom a per - cutaneous drainage of collections was not possible. All were subjected to a laparoscopic peritoneal lavage and debridement. Results: The mean body mass index of patients was 30.3 kg/m 2 . Operative time was 55 ± 28 min and there was no need for ostomies or conversion to open surgery. Two patients had complications. One required a percutaneous drainage of a collection and other required an open surgical procedure for peritoneal lavage. Patients stayed with nil per os for 2 ± 1 days, required antimicrobials for 14 ± 4 days and stayed in the hospital for 8 ± 4 days. Conclusions: Laparoscopic peritoneal lavage is a good alternative surgical procedure for the treatment of acute diverticulitis.

Antimicrobial Therapy for Acute Colonic Diverticulitis

Although guidelines and reviews have systematically evaluated diagnosis and surgical management of acute diverticulitis, they have focused only minimally on antibiotic selection for the treatment of this disease. We undertook a review of the literature to assess more clearly the use of specific antimicrobial agents in the treatment of patients with acute diverticulitis of the colon. A MEDLINE search was conducted to identify original research, review papers, and guidelines on the use of antimicrobial agents for the treatment of acute diverticulitis. The general recommendation to use antibiotics with activity against common gram-negative and anaerobic pathogens has remained consistent. A number of single agents and combination regimens provide such activity. However, there is little evidence on which to base selection of specific antimicrobial regimens, and no regimen has demonstrated superiority. In general, episodes of diverticulitis severe enough to warrant hospitalization should be managed initially with intravenous antibiotics. Oral therapy can be used for outpatient treatment or when the patient's condition improves. There is a paucity of data regarding the optimal duration of antimicrobial therapy. Careful clinical studies are needed to evaluate better the antibiotic regimens for the treatment of acute diverticulitis. Until such studies are conducted, we are forced to rely on tradition, in vitro analyses, pharmacokinetic profiling, and indirect evidence from studies of complicated intra-abdominal infections to determine appropriate therapy for this disease.

Emergent and Elective Surgery for Diverticulitis

The scientific evidence and basis for standardized treatment for diverticulitis has been questioned. For years, medical and surgical management of acute diverticulitis included the theory that more than 2 significant attacks of diverticulitis would lead to the recommendations of surgical resection. This should be questioned and further investigated with prospective randomized trials. Only a small number of well-published articles support the surgical management with good scientific data. Although our ability to take a history and skill of physical examination has not changed, the use of improved technology such as high-speed computerized axial tomography has afforded us the ability to make earlier and more accurate diagnoses. This may further allow us to standardize treatment and study outcomes. It is possible that only the most critical situations may necessitate an operation. The age group less than 40 years, the immunocompromised, steroid-dependent, diabetic, and transplant patients, seem to be at greater risk with increased morbidity if not treated early and aggressively. Those individuals who present with perforation or compromised obstruction most likely will continue to need emergent intervention. But we need to reevaluate who needs surgical intervention while remaining within the confines of excellent and cost-effective care.

Diagnosis and Management of Acute Diverticulitis

Although the diagnosis of acute diverticulitis is somewhat standardized, the scientific evidence and basis for treatment has been questioned. For years, medical and surgical management of acute diverticulitis has been based on the theory that more than 2 significant attacks of diverticulitis would lead to the recommendations of surgical resection. This should be questioned and further investigated with prospective randomized trials. Only a small number of well-published articles support the surgical management with good scientific data. Although our ability to take a history and skill of physical examination has not changed, the use of improved technology such as high-speed computerized axial tomography has afforded us the ability to make earlier and more accurate diagnoses. This may further allow us to standardize treatment and study outcomes. The time has come to further investigate and justify this management. It is possible that only the most critical situations may necessitate an operation. Clearly, the age group less than 40 years, as well as the immunocompromised, steroid-dependent, diabetic, and transplant patients, seem to be at greater risk with increased morbidity if not treated early and aggressively. And those individuals who present with perforation or compromised obstruction most likely will continue to need emergent intervention. We should try to set the rules by evidence-based medicine, while remaining within the confines of excellent and cost-effective care.