Surgical Treatment Of Acute Diverticulitis Research Articles

Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure.

To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population. Retrospective multi-institute database cohort analysis. American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database. The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65years, 65-79years, ≥80years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression. A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79years [odds ratio (OR) 2.39, P < .001] and ≥80years (OR 6.28, P < .001) compared to patients aged <65years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80years (OR 2.63, P= .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P= .001). In patients aged ≥80years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P= .04). Thirty-day mortality was also lower in patients aged ≥80years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P= .03) but similar for patients aged 65-79years (OR 0.81, P= .70). In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.

Professional responsibility between guidelines and customary practice. A conflict of interest?

In Countries with Common Law, the principles of medical liability in case of malpractice claim are based on the Bolam/Bolitho tests, that is, the opinion of a panel of average professionals of the same specialty. On the contrary, in Countries whose legal system is based on the Corpus Iustinianeum the practice of a doctor is benchmarked against established guidelines. Occasionally, the opinion of an expert panel may not overlap the formal guidelines, in particular in cases like the surgical treatment of acute diverticulitis and that of acute cholecystitis where pre-existing old-fashioned ideas are so rooted into the behaviour of doctors that they are extremely difficult to eradicate despite the growing amount of evidence. This may lead to the paradox that a doctor who followed the guidelines might be considered imprudent or negligent as his or her choice did not overlap that of the “average” professional. This is a grey area that needs clarification. We propose that the “expert panel” nominated during a medical malpractice claim should not report their personal – although shared – opinion, but should unbiasedly report all the available acceptable options. Criminal and civil courts, along with other medical panels, must consider this bias when scrutinizing the practice of a professional.

Surgical Treatment of Diverticulitis

Surgical evaluation and treatment is commonly required for the treatment of diverticulitis in both the acute and elective situations. This chapter discusses the surgical treatment of the clinically important manifestations of diverticular disease. Different options for surgical treatment are described for patients in both the urgent and elective settings, including technical aspects of these options. Current controversies are reviewed, including resection versus laparoscopic lavage for the treatment of purulent peritonitis, the use of gastrointestinal diversion in the surgical treatment of acute diverticulitis, and timing of operation for recurrent diverticulitis. This review contains 8 figures, 4 tables, and 67 references. Key Words: acute diverticulitis, complicated diverticulitis, diverticular disease, diverticulitis, diverticulosis, Hartmann procedure, laparoscopic lavage, sigmoid resection with primary anastomosis, uncomplicated diverticulitis

Traitement de la diverticulite aiguë sigmoïdienne : revue de la littérature

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.

Advances in management of patients with acute diverticulitis

ObjectiveTo analyse the development of the medical and surgical treatment of acute diverticulitis to develop an appropriate decision-making algorithm. MethodsWe analysed the demographic characteristics, radiological images, disease severity, treatments and surgical outcomes of all of the patients with a diagnosis of acute diverticulitis admitted to the Department of General and Emergency Surgery between 1 January 2009 and 30 June 2014. ResultsDuring the 66-month study period, 219 patients with acute diverticulitis attended our department; 69% had simple diverticulitis (93% were treated conservatively and 7% surgically) and 31% had complicated diverticulitis (76% were treated surgically and 24% conservatively). Of the patients who were treated surgically, 62.5% underwent primary resection with anastomosis, 31.94% Hartmann's procedure, and 5.56% laparoscopic lavage and drainage. ConclusionsOur cases and a careful review of the literature allowed us to develop a decision-making algorithm for patients with acute diverticulitis.

Resection and primary anastomosis with proximal diversion instead of Hartmann's

The emergency surgical treatment of acute diverticulitis with feculent or purulent peritonitis has traditionally been the Hartmann's procedure (HP). Debate continues over whether primary resection with anastomosis and proximal diversion may be performed in the setting of a high-risk anastomosis in complicated diverticular disease. In contrast to a loop ileostomy takedown, the morbidity of a Hartmann's reversal is preventative for many patients, leaving them with a permanent stoma. Our study compared the surgical outcomes of patients with perforated diverticulitis who underwent a HP to primary anastomosis with proximal diversion (PAPD). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2009 to identify all cases of perforated diverticulitis classified as contaminated or dirty/infected. Patients were stratified into HP or PAPD, and logistic regression models were created to control for patient demographics, comorbidities, perioperative risk, and illness severity to determine the impact of surgical procedure on outcome. There were 2,018 patients meeting the inclusion criteria of which 340 (17%) underwent PAPD and the remainder underwent HP. Significant independent predictors of infectious outcomes were alcohol use, preoperative sepsis, and operative time. There was no significant difference in risk of infectious complications, return to the operating room, prolonged ventilator use, death, or hospital length of stay between the two procedures. When considering only dirty/infected cases, the mortality risk was twofold greater when PAPD was performed. The treatment of acute diverticulitis in the setting of contamination can be safely treated with resection, primary anastomosis, and proximal diversion as opposed to a HP in certain circumstances. Given the decreased morbidity of subsequent loop ileostomy takedown compared with a Hartmann's reversal, this procedure should be given consideration in the management of acute, perforated diverticulitis but may not be warranted in cases of feculent peritonitis.

Article review: Left-sided acute diverticulitis

Background. The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. Methods. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. Results. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32.6%) underwent emergency surgery at accrual. After a mean follow-up of 10.7 years, rates of recurrence (17.2% vs. 5.8%; P < 0.001) and emergency surgery (6.9% vs. 1.3%; P = 0.021) were higher in medically treated patients than in those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1% and diseaserelated mortality was zero in this group. The disease-related mortality rate was 0.6% among patients who had surgical treatment. Conclusion. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Multicentre observational study of the natural history of left-sided acute diverticulitis

The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Surgical therapy of acute diverticulitis

Following conservative treatment of acute colonic diverticulitis at least one fourth of the patients experiences a further attack. The complication rate rises up to 60% at the recurrence. Therefore, colon resection is indicated at/following the second attack. For male patients below 50 years of age and with severe first attack, surgery is recommended already at/following the first attack. In the absence of diffuse fecal peritonitis, the one-stage colon resection with primary anastomosis is widely accepted, now. Percutaneous drainage of a peridiverticular or paracolic abscess is hazardous (success rate 70%), dangerous (consecutively delayed elimination of septic focus, 5% complication rate of drainage itself) and not necessary or helpful. Recurrent diverticulitis following sigmoid resection rarely occurs (1-11%) and is avoidable by removal of at least 20 cm colon including the rectosigmoid junction and anastomosis to the rectum. An extension of the resection towards cephalad direction to remove as much diverticula as possible seems not to decrease the risk of recurrent disease and is therefore not worthwhile.

Surgical Management of Complicated Diverticulitis

The majority of patients with acute diverticulitis can be managed medically. Some will have a complication of diverticulitis such as free perforation with peritonitis, abscess formation, obstruction, or fistula formation. Perhaps even a larger number will develop recurrent diverticulitis, which is associated with an increased rate of complications. Although the preoperative diagnosis of these problems may be obvious in many patients, elderly or steroid-treated patients may have few manifestations of significant intra-abdominal disease. Of extreme importance in the management of these complications of diverticulitis is the preoperative resuscitation. Intravascular volume depletion is replaced with intravenous fluids, and intravenous antibiotics are given. At this time, with any of these complications, it is unusual to perform the classic three-stage operation, which includes an initial diverting colostomy and drainage followed by resection of the involved colon and, finally, a colostomy closure as the third stage. The usual treatment now is a two-stage operation with the initial operation being resection of the diseased segment and formation of a colostomy proximally and either a mucous fistula or a Hartmann's pouch distally. The second stage is the colostomy closure. This two-stage approach is indicated in patients with acute diverticulitis complicated by perforation, whether free or confined with abscess formation, and in patients with obstruction or fistula formation in whom a preoperative bowel preparation is not possible. Resection and primary anastomosis should not be performed in the elderly in the emergency setting for complicated diverticulitis. However, this is the procedure of choice in the elective treatment of diverticulitis and its complications in the elderly.

Surgical Treatment of Acute Diverticulitis by Staged Procedures

A retrospective 10-year experience with the traditional three-stage plan (diverting colostomy, resection, colostomy closure) for perforated diverticulitis of the colon in four urban hospitals was reviewed to accurately assess the mortality rate. Only patients who were admitted in a non-elective manner with signs of an acute abdomen or who were already hospitalized with another illness and developed an acute abdomen were considered. Fecal or generalized purulent peritonitis, or pelvic peritonitis with abscess were observed at laparotomy in all instances. Two hundred and eight patients representing 211 episodes met the above stated criteria for inclusion in the study. A transverse colostomy was performed in 203 instances associated with 16 deaths, and 8 sigmoid colostomies were associated with two deaths. The overall mortality after the first stage was 8.5%. A loop colostomy was constructed most frequently and a completely divided colostomy performed in only 31 of 211 (15%) instances. Of 147 instances in which the diseased sigmoid colon was resected, 44 (30%) had the colostomy ablated at the same operation, resulting in only one death (0.7% mortality). Colostomy closure as a separate procedure in 103 instances resulted in 4 deaths (3.9% mortality). The highest mortality rate occurred in patients in the in the eighth decade. Staged procedures for perforated colonic diverticula can be carried out with a mortality rate of 11%.