|
1
|
Ceresoli M, Ferro CAP, La Greca A, Cioffi SPB, Biloslavo A, Podda M, Coccolini F. Minimally invasive approach to peritonitis from left colonic perforation: a retrospective multicenter observational study. Surg Endosc 2025; 39:2370-2379. [PMID: 39966134 PMCID: PMC11933178 DOI: 10.1007/s00464-025-11611-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 02/02/2025] [Indexed: 02/20/2025]
Abstract
BACKGROUND Laparoscopic procedures have nowadays become the gold standard in multiple abdominal diseases, but in the emergency setting, especially in major surgery, laparoscopy still represents an obstacle for most surgeons. This multicentric study aims to define the surgical approach for emergency resective surgery in left colonic perforation peritonitis, determine the factors influencing the choice between MIS and open surgery, and identify factors associated with laparotomic conversion. METHODS Retrospective data from 516 patients treated for left colonic perforation between January 2019 and December 2023 across six Italian centers was collected. Variables analyzed included patient demographics, disease and surgical characteristics, post-operative complications, and long-term outcomes. Univariate and multivariate regression models were performed to identify factors associated with surgical choice and likelihood of conversion. RESULTS Only 24.5% of patients underwent laparoscopic approach, with a conversion rate of 52.8%. MIS was associated to lower CCI and MPI and less severe septic status at arrival. MIS was mostly performed by colorectal surgeons, compared to acute care surgeons. The post-operative outcome, considering LOS, ICU admission, post-operative complications and mortality rate, was better in the MIS group. The multivariate regression model revealed that CCI, MPI, and night-time surgery were negatively associated with MIS while colorectal surgeons had a positive association. Laparotomic conversion more commonly occurred in older patients with a higher MPI and CCI and more severe septic status; these patients had a worse post-operative outcome. MPI was the only factor with statistical significance in the univariate analysis, associated with conversion. CONCLUSION Although MIS is associated with better post-operative outcomes, it is underutilized in the emergency setting. Patients requiring laparotomic conversion had higher morbidity and mortality compared to those who underwent successful laparoscopy. Limiting factors for MIS include logistic factors, patient severity, and surgical skills, therefore careful patient selection and surgical training is crucial.
Collapse
Affiliation(s)
- Marco Ceresoli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of General and Emergency Surgery, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Carola Anna Paolina Ferro
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Department of General and Emergency Surgery, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
| | - Antonio La Greca
- Emergency Surgery and Trauma Unit, Fondazione IRCSS Policlinico Universitario A Gemelli Roma, Rome, Italy
| | | | - Alan Biloslavo
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| |
Collapse
|
|
2
|
Móré D, Erdmann S, Bischoff A, Wagner V, Kauczor HU, Liesenfeld LF, Abbasi Dezfouli K, Giannakis A, Klauß M, Mayer P. Comparison of Non-Contrast CT vs. Contrast-Enhanced CT with Both Intravenous and Rectal Contrast Application for Diagnosis of Acute Colonic Diverticulitis: A Multireader, Retrospective Single-Center Study. Diagnostics (Basel) 2024; 15:29. [PMID: 39795557 PMCID: PMC11719699 DOI: 10.3390/diagnostics15010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Accepted: 12/24/2024] [Indexed: 01/13/2025] Open
Abstract
Objectives: To evaluate the non-inferiority of non-contrast CT compared to contrast-enhanced CT with both intravenous and rectal contrast application for the diagnosis of acute colonic diverticulitis. Methods: Five readers retrospectively evaluated the non-contrast and contrast-enhanced series of CTs of 205 consecutive patients with clinical suspicion of acute diverticulitis. Two randomized reading sessions, both containing all 205 cases as either contrast-enhanced or non-contrast (1:1) series, were performed with ≥8 weeks washout between them. The non-inferiority margin was set to 0.1. Results: The pooled prevalence (all readers) of diverticulitis was similar for non-contrast CT (63.9%, range: 60.5-65.0%) and contrast-enhanced CT (64.4%, 61.5-67.8%). Non-contrast CT was non-inferior for the diagnosis of diverticulitis (accuracy 0.90 [95% confidence interval: 0.89, 0.92]) compared to contrast-enhanced CT (0.92 [0.90, 0.94]; the difference in accuracy: -0.01 [-0.04, 0.01]) (normal deviate test: p-valueone-sided = 5.20 × 10-6). Sensitivities for perforation and abscess were slightly but significantly lower for the non-contrast CT than for the contrast-enhanced CT (differences: -0.15 [-0.20, -0.05], -0.17 [-0.27, -0.07]), while no differences in accuracies and specificities were observed. Conclusions: Non-contrast CT is non-inferior to contrast-enhanced CT (intravenous and rectal contrast) for the diagnosis of acute colonic diverticulitis. Contrast-enhanced CT is associated with significantly higher sensitivities for the presence of an abscess or perforation.
Collapse
Affiliation(s)
- Dorottya Móré
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Stella Erdmann
- Institute of Medical Biometry, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Arved Bischoff
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Verena Wagner
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Hans-Ulrich Kauczor
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Lukas F. Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Katharina Abbasi Dezfouli
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Athanasios Giannakis
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Miriam Klauß
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| | - Philipp Mayer
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.M.); (A.B.); (V.W.); (H.-U.K.); (K.A.D.); (A.G.); (M.K.)
| |
Collapse
|
|
3
|
Enciu O, Toma EA, Miron A, Popa GL, Muntean AA, Porosnicu AL, Popa MI. Caught Between Stewardship and Resistance: How to Treat Acute Complicated Diverticulitis in Areas of Low Antimicrobial Susceptibility? Antibiotics (Basel) 2024; 13:1150. [PMID: 39766542 PMCID: PMC11672426 DOI: 10.3390/antibiotics13121150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Revised: 11/27/2024] [Accepted: 11/29/2024] [Indexed: 01/04/2025] Open
Abstract
Antimicrobial resistance is one of the main threats to public health, with multidrug-resistant (MDR) pathogens on the rise across continents. Although treatment guidelines generally recommend antimicrobial therapy for acute complicated diverticulitis, they do not specify treatment pathways according to local or national resistance profiles. There is sparse data regarding specific pathogens involved in Hinchey II-IV patients who undergo surgery. This study seeks to address these issues and determine how often and what types of MDR bacteria occur in patients undergoing emergency surgery. We prospectively enrolled patients admitted between 2020-2023 and who underwent emergency surgery for complicated acute diverticulitis. We analysed the inflammatory response parameters at admission, the type of surgery employed for source control, identified pathogens in the peritoneal samples, their antimicrobial susceptibility, the efficacy of antimicrobial empiric therapy, and mortality. Gram-negative bacteria were identified most often, with Escherichia coli being mostly MDR (43.9%) or extended-spectrum beta-lactamase producing (ESBL +ve) (24.4%), while most strains of Klebsiella pneumoniae were extended-spectrum beta-lactamase positive (ESBL +ve) (80%) and MDR (80%). Of the Enterococcus spp., 57.14% were vancomycin-resistant (VRE) strains. Patients with Hinchey III/IV were significantly more associated with MDR. Patients with multiple pathogens were significantly associated with ESBL+/VRE strains. Age, leucocytosis, and procalcitonin levels at admission were good indicators for mortality prediction, which occurred in four cases. In an age when antibiotic stewardship is advisable especially in emergency settings, the treatment should be tailored according to local profiles of MDR to ensure adequate outcomes for patients.
Collapse
Affiliation(s)
- Octavian Enciu
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- Emergency Hospital-Surgery Department, Elias University, 020021 Bucharest, Romania
| | - Elena-Adelina Toma
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- Emergency Hospital-Surgery Department, Elias University, 020021 Bucharest, Romania
| | - Adrian Miron
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- Emergency Hospital-Surgery Department, Elias University, 020021 Bucharest, Romania
| | - Gabriela Loredana Popa
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- Colentina Clinical Hospital-Parasitic Disease Department, 020021 Bucharest, Romania
| | - Andrei-Alexandru Muntean
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- The “Cantacuzino” National Medico-Military Institute for Research and Development, 020021 Bucharest, Romania
| | - Andrei Ludovic Porosnicu
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- Emergency Hospital-Surgery Department, Elias University, 020021 Bucharest, Romania
| | - Mircea Ioan Popa
- Department of Microbiology, “Cantacuzino” Institute, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (O.E.); (A.M.); (G.L.P.); (A.-A.M.); (A.L.P.); (M.I.P.)
- The “Cantacuzino” National Medico-Military Institute for Research and Development, 020021 Bucharest, Romania
| |
Collapse
|
|
4
|
Hernández-Flores LA, Aillaud-De-Uriarte D, Perez-Baca F, Yu A, Marines-Copado D. Assessing a complex patient with both colorectal cancer and diverticulitis of the sigmoid colon: A case report and literature review. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2024; 7:181-185. [DOI: 10.1016/j.lers.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2025] Open
|
|
5
|
Carabotti M, Sgamato C, Amato A, Beltrame B, Binda GA, Germanà B, Leandro G, Pasquale L, Peralta S, Viggiani MT, Severi C, Annibale B, Cuomo R. Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease. Dig Liver Dis 2024; 56:1989-2003. [PMID: 39004551 DOI: 10.1016/j.dld.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.
Collapse
Affiliation(s)
- Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Costantino Sgamato
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
| | | | - Benedetta Beltrame
- Department of Technical-Health Care Professions Dietetics Unit- AUSL Toscana Centro Santa Maria Nuova Hospital, Italy
| | | | - Bastianello Germanà
- Gastroenterology and Digestive Endoscopy San Martino Hospital, Belluno, Italy
| | | | - Luigi Pasquale
- Gastroenterology and Digestive Endoscopy, Avellino, Italy
| | - Sergio Peralta
- UOS Diagnostic and Interventional Digestive Endoscopy AOU Policlinico P.Giaccone, Palermo, Italy
| | | | - Carola Severi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
| |
Collapse
|
|
6
|
Alshandeer MH, Abd El Maksoud WM, Abbas KS, Al Amri FS, Alghamdi MA, Alzahrani HA, Dalboh A, Bawahab MA, Asiri AJ, Assiri Y. Does type II diabetes mellitus increase the morbidity of patients with diverticulitis? Medicine (Baltimore) 2024; 103:e40567. [PMID: 39560541 PMCID: PMC11576019 DOI: 10.1097/md.0000000000040567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 10/29/2024] [Indexed: 11/20/2024] Open
Abstract
Diverticular disease is a common condition that has numerous complications. Understanding the impact of diabetes mellitus (DM) on these complications, especially diverticulitis, is crucial for optimizing patient care. This study aimed to determine the relationship between type II DM and the complications of colonic diverticulitis. A retrospective cohort study was conducted on 158 patients complaining of diverticulitis at Asir Central Hospital, Abha, Saudi Arabia, between January 2013 and December 2023. Data on gender, age, and chronic diseases, especially DM, were collected. Data retrieved regarding diverticulitis included the involved segment, complications, Hinchey classification, and management. We classified the patients into groups A for nondiabetics and B for diabetics. We analyzed the data using descriptive statistics, chi-square tests, t tests, and analysis of variance. Diabetic patients were significantly older than their nondiabetic counterparts. Diabetic patients showed a significantly higher complication rate (62.5%) and a higher degree of Hinchey classification compared to nondiabetic patients (43.7%). Furthermore, in comparison to individuals without diabetes, they were hospitalized for a considerably extended period (8.06 ± 7.38 days vs 5.26 ± 5.90 days, respectively). In addition, surgical intervention was observed to be considerably more common in patients with diabetes (46.9%) than in those without diabetes (16.5%). The study showed that DM adversely affected patients with diverticulitis. A greater incidence of complications and a higher category of Hinchey classification were associated with DM compared to nondiabetics. Additionally, diabetics underwent more surgical interventions and had longer hospital stays. Diabetics with diverticulitis require particular care to prevent severe complications.
Collapse
Affiliation(s)
- Marei H. Alshandeer
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | | | - Khaled S. Abbas
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Fahad S. Al Amri
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Maha A. Alghamdi
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Hassan A. Alzahrani
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Abdullah Dalboh
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Mohammed A. Bawahab
- Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Aisha J. Asiri
- Surgery Department, Aseer Central Hospital, Abha, Saudi Arabia
| | - Yahia Assiri
- Department of Medicine (Radiology Division), College of Medicine, King Khalid University, Abha, Saudi Arabia
| |
Collapse
|
|
7
|
Troester A, Weaver L, Jahansouz C. The Emerging Role of the Microbiota and Antibiotics in Diverticulitis Treatment. Clin Colon Rectal Surg 2024. [DOI: 10.1055/s-0044-1791521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
AbstractDiverticular disease is the leading cause of elective colon surgery. With a rising incidence in younger populations, it continues to pose a significant burden on the health care system. Traditional etiopathogenesis implicated an infectious mechanism, while recent challenges to this theory have demonstrated the microbiome playing a significant role, along with genetic predispositions and associations with obesity and diet. Therefore, the role of antibiotics in uncomplicated disease merits reconsideration. In this review, we aim to outline the current knowledge regarding antibiotics for diverticulitis treatment, broadly define the microbiome components, functions, and modifiability, and discuss newly proposed pathogenetic mechanisms for diverticular disease that incorporate information regarding the microbiome. Analytic techniques for microbiota characterization and function continue to advance at a rapid pace. As emerging technology advances, we will continue to elucidate the role of the microbiome in diverticular disease development.
Collapse
Affiliation(s)
| | - Lauren Weaver
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Cyrus Jahansouz
- Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
|
8
|
Simonetti S, Lanciotti S, Carlomagno D, De Cristofaro F, Galardo G, Cirillo B, Fiore F, Bonito G, Severi C, Ricci P. Acute diverticulitis: beyond the diagnosis: predictive role of CT in assessing risk of recurrence and clinical implications in non-operative management of acute diverticulitis. LA RADIOLOGIA MEDICA 2024; 129:1118-1129. [PMID: 39039300 PMCID: PMC11322399 DOI: 10.1007/s11547-024-01841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE The aim of the study is to identify CT findings that are predictive of recurrence of acute uncomplicated colonic diverticulitis, to better risk-stratify these patients for whom guidelines recommend a conservative outpatient treatment and to determine the appropriate management with an improvement of health costs. MATERIALS AND METHODS Over the past year, 33 patients enrolled in an outpatient integrated care pathway (PDTA) for uncomplicated acute diverticulitis with 1-year follow-up period, without recurrence, and 33 patients referred to Emergency Department for a recurrent acute diverticulitis were included. Images of admission CT were reviewed by two radiologists and the imaging features were analyzed and compared with Chi-square and Student t tests. Univariate and multivariate Cox regression models were employed to identify parameters that significantly predicted recurrence in 1-year follow-up period and establish cutoff and recurrence-free rates. The maximally selected rank statistics (MSRS) were used to identify the optimal wall thickening cutoff for the prediction of recurrence. RESULTS Patients with recurrence showed a greater mean parietal thickness compared to the group without recurrence (16 mm vs. 11.5 mm; HR 1.25, p < 0.001) and more evidence of grade 4 of peridiverticular inflammation (40% vs. 12%, p = 0.009, HR 3.44). 12-month recurrence-free rates progressively decrease with increasing thickness and inflammation. In multivariate analysis, only parietal thickness maintained its predictive power with an optimal cutpoint > 15 mm that causes a sixfold increased risk of recurrence (HR 6.22; 95% CI, 3.05-12.67; p < 0.001). Beyond thickness and peridiverticular inflammation, predictive value of early recurrence within 90 days from the 1st episode resulted also an Hinchey Ib on admission CT. CONCLUSIONS The maximum wall thickening and the grade of peridiverticular inflammation can be considered as predictive factors of recurrence and may be helpful in selecting patients for a tailored treatment to prevent the risk of recurrence.
Collapse
Affiliation(s)
- Stefania Simonetti
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Silvia Lanciotti
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - Dominga Carlomagno
- Translation and Precision Medicine Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Flaminia De Cristofaro
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Gioacchino Galardo
- Emergency Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Bruno Cirillo
- Emergency Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Fabio Fiore
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giacomo Bonito
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carola Severi
- Translation and Precision Medicine Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Ricci
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy.
| |
Collapse
|
|
9
|
Serrano González J, Román García de León L, Galindo Jara P, Lucena de la Poza JL, Sánchez Movilla A, Colao García L, García Schiever JG, Varillas Delgado D. Non-antibiotic treatment of uncomplicated acute diverticulitis is applicable and safe in our environment. A prospective multicenter study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:140-147. [PMID: 37929981 DOI: 10.17235/reed.2023.9737/2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION acute diverticulitis is one of the most frequent underlying causes behind individuals attending the Emergency Room with abdominal pain. The most widespread therapy for acute uncomplicated diverticulitis includes outpatient treatment with antibiotics; however, several publications indicate that patients can also be successfully treated without antibiotics. The results of the implementation of this more recent protocol in two hospitals in Madrid are presented. METHODS an observational prospective study was performed. Participants were patients diagnosed with uncomplicated acute diverticulitis at two hospitals in Madrid, Hospital Universitario de Torrejón and Hospital Universitario Puerta de Hierro Majadahonda, between December 2018 and August 2021, treated on an outpatient basis without antibiotic therapy. The study group was compared with a control group, composed of patients diagnosed with uncomplicated acute diverticulitis and treated with outpatient antibiotic therapy at Hospital Universitario Puerta de Hierro between March 2015 and March 2018. RESULTS three hundred and sixty-one patients were included, 182 in the study group and 179 in the control group. Diverticulitis was persistent in 19 patients (10.4 %) in the study group, who were not treated with antibiotics, and in five patients (2.8 %) in the control group, treated with outpatient antibiotic therapy (p = 0.004). Recurrences occurred in 23 patients (12.6 %) in the study group, and in 53 patients (29.6 %) in the control group (p < 0.0001). The analysis of the complications found no significant differences between both groups (p = 0.109). No urgent surgical intervention or mortality was recorded in the study group. CONCLUSIONS in our environment, symptomatic non-antibiotic treatment of uncomplicated acute diverticulitis cases is safe, without showing a higher rate of complications. Although, there seems to be a worse initial symptom control.
Collapse
|
|
10
|
Vijfschagt ND, de Boer MR, Berger MY, Burger H, Holtman GA. Accuracy of diagnostic tests for acute diverticulitis that are feasible in primary care: a systematic review and meta-analysis. Fam Pract 2024; 41:1-8. [PMID: 38271592 PMCID: PMC10901479 DOI: 10.1093/fampra/cmad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Recognition of acute diverticulitis is important to determine an adequate management strategy. Differentiating it from other gastrointestinal disorders is challenging as symptoms overlap. Clinical tests might assist the clinician with this diagnostic challenge. Previous reviews have focussed on prognostic questions and imaging examinations in secondary care. OBJECTIVE To evaluate the diagnostic accuracy of clinical tests feasible in primary care for acute diverticulitis in suspected patients. METHOD We have systematically searched multiple databases for diagnostic accuracy studies of tests feasible in primary care compared to a reference standard in suspected patients. Two reviewers independently selected studies, extracted data, and assessed study quality with the QUADAS-2 tool. We have meta-analysed the results in the case of more than four studies per index test. RESULTS Seventeen studies were included, all studies were performed in secondary care (median prevalence 48%). Individual signs and symptoms showed a wide range in sensitivity (range 0.00-0.98) and specificity (range 0.08-1.00). Of the four laboratory tests evaluated, CRP >10 mg/l had the highest sensitivity (range 0.89-0.96) with specificity ranging from 0.28 to 0.61. Ultrasound had the highest pooled sensitivity and specificity of 0.92 (95% CI 0.86-0.96) and 0.94 (95% CI 0.88-0.97), respectively. CONCLUSION None of the studies were performed in primary care. Individual signs and symptoms alone are insufficiently informative for acute diverticulitis diagnosis. CRP showed potential for ruling out and ultrasound had a high diagnostic accuracy. More research is needed about the diagnostic accuracy of these tests in primary care. PROSPERO REGISTRATION NUMBER CRD42021230622.
Collapse
Affiliation(s)
- Natasja D Vijfschagt
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel R de Boer
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gea A Holtman
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
|
11
|
Seta T, Iwagami H, Agatsuma N, Noma A, Ikenouchi M, Kubo K, Akamatsu T, Uenoyama Y, Ito D, Yamashita Y, Nakayama T. Efficacy of antimicrobial therapy in patients with uncomplicated acute colonic diverticulitis: an updated systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2023; 35:1097-1106. [PMID: 37577799 DOI: 10.1097/meg.0000000000002622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.
Collapse
Affiliation(s)
- Takeshi Seta
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
- Department of Health Informatics, Graduate School of Medicine & School of Public Health, Kyoto University
| | - Hiroyoshi Iwagami
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Nobukazu Agatsuma
- Departments of Gastroenterology
- Hepatology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto
| | - Atsushi Noma
- Department of Gastroenterological Surgery and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Maiko Ikenouchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Hyogo
| | - Kenji Kubo
- Department of Infectious Diseases and Emergency Medicine, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Takuji Akamatsu
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Yoshito Uenoyama
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Daisuke Ito
- Department of Gastroenterological Surgery and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Yukitaka Yamashita
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Medicine & School of Public Health, Kyoto University
| |
Collapse
|
|
12
|
Cirocchi R, Duro F, Avenia S, Capitoli M, Tebala GD, Allegritti M, Cirillo B, Brachini G, Sapienza P, Binda GA, Mingoli A, Fedeli P, Nascimbeni R. Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review. J Clin Med 2023; 12:5522. [PMID: 37685590 PMCID: PMC10488020 DOI: 10.3390/jcm12175522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses. MATERIAL AND METHODS A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. CONCLUSIONS Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
Collapse
Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Francesca Duro
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Stefano Avenia
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Matteo Capitoli
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | | | | | - Bruno Cirillo
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Paolo Sapienza
- Department of Surgery, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy;
| | | | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | | | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy;
| |
Collapse
|
|
13
|
Nocera F, Haak F, Posabella A, Angehrn FV, Peterli R, Müller-Stich BP, Steinemann DC. Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients. Langenbecks Arch Surg 2023; 408:295. [PMID: 37535118 PMCID: PMC10400669 DOI: 10.1007/s00423-023-03034-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/28/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE Weighing the perioperative risk of elective sigmoidectomy is done regardless of the specific diverticulitis classification. The aim of this study is to evaluate surgical outcomes according to the classification grade and the indication. METHODS All patients who underwent elective colonic resection for diverticulitis during the ten-year study period were included. They were divided into two groups: relative surgery indication (RSI) and absolute surgery indication (ASI). RSI included microabscess and recurrent uncomplicated disease. ASI included macroabscess and recurrent complicated disease. Propensity score-matching (PSM, 1:1) was performed. RESULTS 585 patients fulfilled criteria for RSI and 318 patients fulfilled criteria for ASI. In the univariate analysis, RSI patients were younger (62 vs. 67.7 years, p < 0.001), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p < 0.001), were less immunosuppressed (3.4% vs. 6.9%, p = 0.021) and suffered less often from coronary heart disease (3.8% vs. 7.2%, p = 0.025). After PSM, 318 RSI vs. 318 ASI patients were selected; baseline characteristics results were comparable. The proportion of planned laparoscopic resection was 93% in RSI versus 75% in ASI (p < 0.001), and the conversion rate to open surgery for laparoscopic resection was 5.0% and 13.8% in RSI versus ASI, respectively (p < 0.001). Major morbidity (Clavien/Dindo ≥ IIIb) occurred less frequently in RSI (3.77% vs. 10%, p = 0.003). A defunctioning stoma was formed in 0.9% and 11.0% in RSI vs ASI, respectively (p < 0.001). CONCLUSION The lower risk for postoperative morbidity, the higher chance for a laparoscopic resection and the decreased rate of stoma formation are attributed to patients with recurrent uncomplicated diverticulitis or diverticulitis including a microabscess as compared to patients with complicated diverticulitis or diverticulitis and a macroabscess, and this applies even after PSM.
Collapse
Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
- Departmen of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland
| | - Fabian Haak
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
- Departmen of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland
| | - Alberto Posabella
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Valente Angehrn
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Ralph Peterli
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Beat P Müller-Stich
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Departmen of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
| |
Collapse
|
|
14
|
Saren R, Aspegren S, Paajanen H, Ukkonen M, Käkelä P. Incidence of acute diverticulitis compared to appendicitis in emergency wards: a 10-year nationwide register and cohort study from Finland. Scand J Gastroenterol 2023; 58:151-156. [PMID: 35977082 DOI: 10.1080/00365521.2022.2111225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The two most common abdominal infections in emergency departments (ED) are acute appendicitis (AA) and sigmoid diverticulitis (AD). The frequency of ED visits for diverticulitis has increased strongly in many countries during recent decades. The aim of this study was to analyze the nationwide changes in AD rate requiring hospital admission compared to AA during a 10-year study period. METHODS Register data of AD and AA in the whole of Finland were obtained between the years 2009 and 2018. Changes in the incidence and surgical treatment of AD in the whole country were compared to those of AA. Patient demographics and treatment of AD were analyzed in greater detail from a smaller cohort (n = 614). RESULTS The incidence of AD increased from 262 to 413 cases (58%) per 100,000 inhabitants during 10 years and emergency surgery for AD decreased from 27 to 24 cases per 100,000 (11%). The incidence of AA remained stable and varied from 118 to 124 annual cases per 100,000 inhabitants. In a patient cohort of AD (n = 614), most of the patients (68%) had only one episode of diverticulitis during 10 years; 16% were operated urgently, with a mortality of 8%. Disease-specific mortality increased from 0% to 5.7% along with patient age when comparing the age groups <50 years and > 70 years, respectively. CONCLUSIONS Our study indicates that the incidence of acute diverticulitis is still increasing and is now 2-3 times higher than that of appendicitis in emergency departments.
Collapse
Affiliation(s)
- Roni Saren
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Sami Aspegren
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Mika Ukkonen
- Department of Surgery, Kuopio University Hospital, Finland
| | - Pirjo Käkelä
- University of Eastern Finland, Kuopio, Finland.,Department of Surgery, Kuopio University Hospital, Finland
| |
Collapse
|
|
15
|
Albshesh A, Ukashi O, Lahat A, Kopylov U, Horesh N, Pflantzer B, Laish I. Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy. Colorectal Dis 2023; 25:897-904. [PMID: 36636896 DOI: 10.1111/codi.16481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/30/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on postdiverticulitis colonoscopic findings has not been studied. The aim of this work was to examine the incidence of adenoma detection rate (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopy. METHOD This was a retrospective case-control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. The incidence of neoplasia was compared between patients with and without previous colonoscopy and also with that of a screening population. RESULTS Compared with a healthy control group (n = 975), diverticulitis patients without prior colonoscopy (n = 325) had a significantly higher ADR (26.8% vs. 20.5%, p = 0.019) and invasive CRC rate (0.9% vs. 0%, p = 0.016). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopy (n = 124), only one patient developed AA and there were no cancer cases. CONCLUSIONS A previous normal colonoscopy within 5 years before diverticulitis probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.
Collapse
Affiliation(s)
- Ahmad Albshesh
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Offir Ukashi
- Department of Internal Medicine A, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Lahat
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Horesh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery and Transplantations B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Barak Pflantzer
- Department of Internal Medicine A, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ido Laish
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
|
16
|
Muacevic A, Adler JR, Pereira J, Biloslavo A, Zago M, Hashem JH, Kumar N, Corbally M, Bass GA, Walsh TN. Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study. Cureus 2023; 15:e33292. [PMID: 36741667 PMCID: PMC9893173 DOI: 10.7759/cureus.33292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment. Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.
Collapse
|
|
17
|
Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: Value of current severity classification schemes. RADIOLOGIA 2023; 65:32-42. [PMID: 36842784 DOI: 10.1016/j.rxeng.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/28/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
Collapse
|
|
18
|
Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer AG, Leifeld L. German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J 2022; 10:940-957. [PMID: 36459576 PMCID: PMC9731665 DOI: 10.1002/ueg2.12313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 12/03/2022] Open
Abstract
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
Collapse
Affiliation(s)
- Wolfgang Kruis
- Apl Professor der MedizinischenFakultätUniversität KölnCologneGermany
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikumTU DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐Krankenhaus, SiegenSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg Peter Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas G. Schreyer
- Institut für diagnostische und interventionelle RadiologieMedizinische Hochschule Brandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
| | | |
Collapse
|
|
19
|
GOUVAS N, AGALIANOS C, MANATAKIS DK, PECHLIVANIDES G, XYNOS E. Elective surgery for conservatively treated acute uncomplicated diverticulitis: a systematic review of postoperative outcomes. Minerva Surg 2022; 77:591-601. [DOI: 10.23736/s2724-5691.22.09726-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
|
20
|
Imam A, Steiner E, Imam R, Omari L, Lin G, Khalayleh H, Pines G. Identifying patients with complicated diverticulitis, is it that complicated? Turk J Surg 2022; 38:169-174. [PMID: 36483174 PMCID: PMC9714650 DOI: 10.47717/turkjsurg.2022.5426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Discriminating simple from complicated diverticulitis solely on clinical bases is challenging. The aim of this study was to identify clinical predictive factor for the need for invasive treatment for patients presenting with acute diverticulitis in the emergency room. MATERIAL AND METHODS The records of all patients, who were discharged from a university hospital between January 2010 and March 2018 with "diverticulitis" diagnosis, were reviewed. Data collected included clinical features, whether this was a first or recurrent episode, WBC, and Hinchey score. Patients were divided into conservative and invasive treatment groups. Groups were compared by age, sex, BMI, fever, WBC and CT findings. Hinchey score groups were also compared by age, sex, BMI, fever, WBC. RESULTS A total of 809 patients were included. Mean age was 60.6 years, with 10% below 40 years. Most patients were treated conservatively (95.9%) while only 4.1% were treated invasively. WBC at presentation was significantly higher in those who required invasive treatment in comparison with the conservative group (13.72 vs. 11.46K/uL, p= 0.024). A statistically significant higher WBC was found among patients with a higher Hinchey score (13.16 vs 11.69, p <0.005). No difference between the groups was found in terms of age, sex, fever or BMI. CONCLUSION This study showed that patients who present with acute diverticulitis and an elevated WBC are prone to a more severe disease and a higher Hinchey score. Prudence should be taken with these patients, and CT scan is warranted as there is a greater chance that invasive treatment will be required.
Collapse
Affiliation(s)
- Ashraf Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Elad Steiner
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Riham Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Loai Omari
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Lin
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Harbi Khalayleh
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Pines
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
| |
Collapse
|
|
21
|
Abstract
BACKGROUND Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable. OBJECTIVES The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery. SEARCH METHODS For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021. SELECTION CRITERIA Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method. MAIN RESULTS The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information. For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited. AUTHORS' CONCLUSIONS The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.
Collapse
Affiliation(s)
- Marie-Louise Dichman
- Department of Surgical Gastroenterology , Hvidovre University Hospital, Copenhagen, Denmark
| | - Steffen Jais Rosenstock
- Department of Surgical Gastroenterology , Hvidovre University Hospital , Copenhagen, Denmark
| | - Daniel M Shabanzadeh
- Department of Surgical Gastroenterology , Hvidovre University Hosipital , Copenhagen, Denmark
| |
Collapse
|
|
22
|
Kang G, Son S, Shin YM, Pyo JS. Recurrence of Uncomplicated Diverticulitis: A Meta-Analysis. Medicina (B Aires) 2022; 58:medicina58060758. [PMID: 35744021 PMCID: PMC9228700 DOI: 10.3390/medicina58060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objective: This study aimed to investigate the estimated rate and risk of recurrence of uncomplicated diverticulitis (UCD) after the first episode through a meta-analysis. Methods: Eligible studies were searched and reviewed; 27 studies were included in this study. Subgroup analyses were performed, based on lesion location, medical treatment, follow-up period, and study location. Results: The estimated recurrence rate of UCD was 0.129 (95% confidence interval [CI] 0.102–0.162). The recurrence rates of the right-and left-sided colon were 0.092 (95% CI 27.063–0.133) and 0.153 (95% CI 0.104–0.218), respectively. The recurrence rate according to follow-up period was highest in the subgroup 1–2 years, compared with that of other subgroups. The recurrence rate of the Asian subgroup was significantly lower than that of the non-Asian subgroup (0.092, 95% CI 0.064–0.132 vs. 0.147, 95% CI 0.110–0.192; p = 0.043 in the meta-regression test). There were significant correlations between UCD recurrence and older age and higher body temperature. However, UCD recurrence was not significantly correlated with medications, such as antibiotics or anti-inflammatory drugs. Conclusions: In this study, detailed information on estimated recurrence rates of UCD was obtained. In addition, older age and higher body temperature may be risk factors for UCD recurrence after the first episode.
Collapse
Affiliation(s)
- Guhyun Kang
- Department of Pathology, Daehang Hospital, Seoul 06699, Korea;
| | - Soomin Son
- Division of Molecular Life and Chemical Sciences, College of Natural Sciences, Ewha Woman’s University, Seoul 03760, Korea;
| | - Young-Min Shin
- Eulji University School of Medicine, Daejeon 34824, Korea;
| | - Jung-Soo Pyo
- Department of Pathology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu 11759, Korea
- Correspondence:
| |
Collapse
|
|
23
|
Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
| | | | | | | | | | | | | | | | | |
Collapse
|
|
24
|
Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
|
25
|
Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: 10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
26
|
Flor N, Innamorati S, Pickhardt P. Radiology. COLONIC DIVERTICULAR DISEASE 2022:153-169. [DOI: 10.1007/978-3-030-93761-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
|
|
27
|
Jerjen F, Zaidi T, Chan S, Sharma A, Mudliar R, Soomro K, Jimenez Y, Reed W. Magnetic Resonance Imaging for the diagnosis and management of acute colonic diverticulitis: a review of current and future use. J Med Radiat Sci 2021; 68:310-319. [PMID: 33607699 PMCID: PMC8424307 DOI: 10.1002/jmrs.458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 12/14/2022] Open
Abstract
Diverticular disease is one of the most common causes of outpatient visits and hospitalisations across Australia, North America and Europe. According to the Gastroenterological Society of Australia (GESA, 2010), approximately 33% of Australians over 45 years of age and 66% over 85 years of age have some form of colonic diverticulosis. Patients with colonic diverticulosis are known to develop subsequent complications such as acute colonic diverticulitis (ACD), and when more than one attack of diverticulitis occurs, there is a 70-90% chance that the individual will experience ongoing problems and recurring infections throughout their lifetime. Medical imaging is fundamental in the diagnosis, treatment and ongoing management of ACD and its complications, with Computed Tomography (CT) identified as the prevailing gold standard in the last few decades. Cross-database searching highlighted a large gap in the literature regarding the effectiveness of Magnetic Resonance Imaging (MRI) as a non-ionising radiation alternative imaging tool for ACD imaging after the mid-2000s, despite ongoing technological advancements in this modality. This narrative review identified 13 key publications (11 primary prospective cohort studies, 1 systematic review and 1 meta-analysis) that evaluate MRI for ACD imaging, of which five were published within the last decade. Several existing MRI protocols are deemed suitable for ACD imaging, and it is recommended they be re-evaluated in larger cohorts. Future studies should consider the rapidly growing technological improvements of MRI, its cost efficiency and its applicability in modern day healthcare settings when addressing ACD management. This is especially important considering the gradual rise in radiation dose among the Australian population attributable to increased CT referrals, alongside increased reporting of ACD cases in younger individuals.
Collapse
Affiliation(s)
- Franziska Jerjen
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Tooba Zaidi
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Shannon Chan
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Ajay Sharma
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Reuel Mudliar
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Khadija Soomro
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Yobelli Jimenez
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| | - Warren Reed
- Medical Imaging Optimisation and Perception Group (MIOPeG)Discipline of Medical Imaging ScienceSydney School of Health SciencesFaculty of Medicine and HealthFranziska Jerjen and Tooba Zaidi are joint first authorsThe University of SydneySydneyNSWAustralia
| |
Collapse
|
|
28
|
Ripollés T, Sebastián-Tomás JC, Martínez-Pérez MJ, Manrique A, Gómez-Abril SA, Torres-Sanchez T. Ultrasound can differentiate complicated and noncomplicated acute colonic diverticulitis: a prospective comparative study with computed tomography. Abdom Radiol (NY) 2021; 46:3826-3834. [PMID: 33765176 DOI: 10.1007/s00261-021-03060-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/06/2021] [Accepted: 03/10/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To prospectively assess the diagnostic value of intestinal ultrasound (US) compared to computerized tomography (CT) in differentiating uncomplicated and complicated acute colonic diverticulitis (ACD). MATERIALS AND METHODS During a period of 14 months patients referred to the department of Radiology with clinical suspicion of ACD underwent an US examination. All confirmed US ACD diagnosis were included and subsequently underwent an emergency abdominal CT, used as gold standard. The WSES (World Society for Emergent Surgery) classification of diverticulitis was used. Diverticulitis was prospectively classified as either uncomplicated or complicated. Sensitivity, specificity, positive predictive value, and negative predictive values of US were evaluated. Before CT scan, the radiologist indicated whether they would have required or not a complementary CT scan, based on US findings. RESULTS Of the 240 patients included in our study, 71 (29.6%) were Stage 0, 127 (53%) Stage 1A, and 42 (17.5%) were moderate-severe ACD (stages 1B, 2A, 2B, 3 and 4). The sensitivity of US for diagnosing complicated ACD was 84% and specificity of 95.8%. Most patients (24 of 27) misclassified by US as uncomplicated diverticulitis were classified on CT as stage 1A. From the 148 cases in which the radiologist considered CT unnecessary, only 3 of these revealed signs of complicated ACD on CT; none of them required emergency surgery. CONCLUSION US is an effective technique to differentiate complicated from uncomplicated ACD. Our results suggest that US, may be a valuable alternative to CT for the initial radiologic evaluation in patients with clinical suspicion of ACD.
Collapse
Affiliation(s)
- Tomás Ripollés
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain.
| | | | - María J Martínez-Pérez
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain
| | - Andrea Manrique
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Avenue, 46017, Valencia, Spain
| | | | | |
Collapse
|
|
29
|
Gavriilidis P, Askari A, Gavriilidis E, de’Angelis N, Di Saverio S, Wheeler J, Davies RJ. Appraisal of the current guidelines for the management of diverticular disease using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. Ann R Coll Surg Engl 2021; 103:471-477. [PMID: 33851878 PMCID: PMC9774019 DOI: 10.1308/rcsann.2021.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Diverticular disease is one of the most frequent reasons for attending emergency departments and surgical causes of hospital admission. In the past decade, many surgical and gastroenterological societies have published guidelines for the management of diverticular disease. The aim of the present study was to appraise the methodological quality of these guidelines using the Appraisal of Guidelines Research and Evaluation II (AGREE II) tool. METHODS PubMed, Embase, Cochrane Library and Google Scholar databases were searched systematically. The methodological quality of the guidelines was appraised independently by five appraisers using the AGREE II instrument. FINDINGS A systematic search of the literature identified 12 guidelines. The median overall score of all guidelines was 68%. Across all guidelines, the highest score of 85% was demonstrated in the domain 'Scope and purpose'. The domains 'Clarity and presentation' and 'Editorial independence' both scored a median of 72%. The lowest scores were demonstrated in the domains 'Stakeholder involvement' and 'Applicability' at 46% and 40%, respectively. Overall, the National Institute for Health and Care Excellence (NICE) guidelines performed consistently well, scoring 100% in five of six domains; NICE was one of the few guidelines that specifically reported stakeholder involvement, scoring 97%. Generally, the domain of 'Stakeholder involvement' ranked poorly with seven of twelve guidelines scoring below 50%, with the worst score in this domain demonstrated by Danish guidelines at 25%. CONCLUSION Six of twelve guidelines (NICE, American Society of Colon & Rectal Surgeons (ASCRS), European Society of Coloproctology (ESCP), American Gastroenterological Association, German Society of Gastroenterology/German Society for General and Visceral Surgery (German), Netherlands Society of Surgery) scored above 70%. Only three, NICE, ASCRS and ESCP, scored above 75% and were voted unanimously by the appraisers for use as they are. Therefore, use of AGREE II may help improve the methodological quality of guidelines and their future updates.
Collapse
Affiliation(s)
- P Gavriilidis
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, UK
| | - A Askari
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - E Gavriilidis
- University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | | | | | - J Wheeler
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - RJ Davies
- Cambridge University Hospitals NHS Foundation Trust, UK
| |
Collapse
|
|
30
|
Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg 2021; 110:180-186. [PMID: 33934672 PMCID: PMC8258726 DOI: 10.1177/14574969211011032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.
Collapse
Affiliation(s)
- A. Chabok
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - A Thorisson
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
- Department of Radiology, Region Västmanland Hospital, Västerås, Sweden
| | - M. Nikberg
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - J. K. Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - V Sallinen
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
|
31
|
Abstract
Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.
Collapse
Affiliation(s)
- Dakota T Thompson
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
| |
Collapse
|
|
32
|
Mikhin IV, Vorontsov OF, Greb K, Nishnevich EV. [Actual issues of diagnosis and treatment of diverticulitis]. Khirurgiia (Mosk) 2021:83-88. [PMID: 33710833 DOI: 10.17116/hirurgia202103183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.
Collapse
Affiliation(s)
- I V Mikhin
- Volgograd State Medical University, Volgograd, Russian Federation
| | - O F Vorontsov
- Volgograd State Medical University, Volgograd, Russian Federation.,Sana Klinikum Hof, Hof, Germany
| | - K Greb
- Sana Klinikum Hof, Hof, Germany
| | - E V Nishnevich
- Ural State Medical University, Ekaterinburg, Russian Federation
| |
Collapse
|
|
33
|
Abstract
BACKGROUND Diverticular disease frequently leads to emergency admissions. Clinical parameters are not sufficiently accurate to determine the extent of acute colonic diverticulitis, thus a quick, reproducible and valid diagnostic imaging procedure is required. OBJECTIVE In the following, the imaging methods commonly used for the diagnostic work-up and staging of diverticulitis are presented and classified in the context of the data situation and clinical reality. RESULTS Multidetector computed tomography (MDCT) is the current diagnostic gold standard for the imaging evaluation of diverticulitis and the basis for guideline-conform treatment decisions according to the classification of diverticular disease (CDD). DISCUSSION The role of magnetic resonance imaging (MRI) in the evaluation of diverticulitis will have to be investigated but a more profound integration of this method can already be predicted. Point-of-care ultrasound for initial diagnosis and follow-up assessment will become more important, analogous to FAST in trauma patients.
Collapse
Affiliation(s)
- Arnd-Oliver Schäfer
- Klinik für Radiologie, Städtisches Klinikum St. Georg Leipzig, Delitzscher Str. 141, 04129, Leipzig, Deutschland.
| |
Collapse
|
|
34
|
Abstract
Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient's health and immune status, and the patient's preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.
Collapse
Affiliation(s)
- Anne F Peery
- University of North Carolina School of Medicine, Chapel Hill, NC 27599-7555, USA
| |
Collapse
|
|
35
|
Sohn M, Agha A, Iesalnieks I, Gundling F, Presl J, Hochrein A, Tartaglia D, Brillantino A, Perathoner A, Pratschke J, Aigner F, Ritschl P. Damage control strategy in perforated diverticulitis with generalized peritonitis. BMC Surg 2021; 21:135. [PMID: 33726727 PMCID: PMC7968247 DOI: 10.1186/s12893-021-01130-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/28/2021] [Indexed: 01/08/2023] Open
Abstract
Background The 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. Methods DCS 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). Results Eight 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. Conclusion DCS 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01130-5.
Collapse
Affiliation(s)
- Maximilian Sohn
- Department of General, Abdominal, Endocrine and Minimally Invasive Surgery, Munich Clinic Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany
| | - Ayman Agha
- Department of General, Abdominal, Endocrine and Minimally Invasive Surgery, Munich Clinic Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany
| | - Igors Iesalnieks
- Department of General, Abdominal, Endocrine and Minimally Invasive Surgery, Munich Clinic Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany
| | - Felix Gundling
- Department of Gastroenterology, Medizinische Klinik II, Sozialstiftung Bamberg, Bamberg Bamberg, Germany
| | - Jaroslav Presl
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | | | - Dario Tartaglia
- Emergency Surgery Unit, Cisanello Hospital, University of Pisa, Pisa, Italy
| | | | - Alexander Perathoner
- Department of Abdominal, Transplant and Thoracic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, 10178, Berlin, Germany
| | - Felix Aigner
- Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria
| | - Paul Ritschl
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, 10178, Berlin, Germany.
| |
Collapse
|
|
36
|
Hanna MH, Kaiser AM. Update on the management of sigmoid diverticulitis. World J Gastroenterol 2021; 27:760-781. [PMID: 33727769 PMCID: PMC7941864 DOI: 10.3748/wjg.v27.i9.760] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/11/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.
Collapse
Affiliation(s)
- Mark H Hanna
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
| | - Andreas M Kaiser
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
| |
Collapse
|
|
37
|
Roson Gradaille N, Narbona Díez A, Garriga Farriol MV, Pruna Comella X, Pedraza Gutiérrez S, López Cano M, Badia JM. Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: value of current severity classification schemes. RADIOLOGIA 2021:S0033-8338(21)00028-X. [PMID: 33612278 DOI: 10.1016/j.rx.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
Collapse
Affiliation(s)
- N Roson Gradaille
- Servicio de Diagnóstico por la imagen, Hospital Universitari Vall d'Hebron, Institut de Diagnòstic per la Imatge (IDI), Barcelona, España.
| | - A Narbona Díez
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - M V Garriga Farriol
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - X Pruna Comella
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - S Pedraza Gutiérrez
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - M López Cano
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - J M Badia
- Servicio de Cirugía General y Aparato Digestivo, Hospital General de Granollers, Granollers, Barcelona, España; Universitat Internacional de Catalunya, Barcelona, España
| |
Collapse
|
|
38
|
Frieling T. [Diverticula in the gastrointestinal tract]. Internist (Berl) 2021; 62:277-287. [PMID: 33560449 DOI: 10.1007/s00108-021-00942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.
Collapse
Affiliation(s)
- Thomas Frieling
- Medizinische Klinik II, Klinik für Innere Medizin mit Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Gastrointestinaler Onkologie, Hämatoonkologie und Palliativmedizin, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Deutschland.
| |
Collapse
|
|
39
|
Abu Baker F, Ganayem M, Mari A, Taher R, Suki M, Kopelman Y. Acute complicated diverticulitis is associated with an increased advanced neoplasia diagnosis rate: A retrospective study on 1852 patients. Medicine (Baltimore) 2021; 100:e24271. [PMID: 33592870 PMCID: PMC7870193 DOI: 10.1097/md.0000000000024271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/11/2020] [Indexed: 01/05/2023] Open
Abstract
Recent reports have documented an unchanged rate of occurrence of colorectal cancer (CRC) and have publicised doubts regarding the benefit of prompt colonoscopy procedures after an episode of acute diverticulitis (AD). These reports mandate further evaluation of colonoscopy yield and timing in this regard. The current study aims to determine whether the rate of advanced colonic neoplasia after AD differs from that of average-risk patients, and to identify risk factors that are associated with their development.In this retrospective study, we included all patients who had been hospitalized to the surgery ward in the years 2008 to 2016 with radiographically confirmed AD, and had completed colonoscopies within one year of index hospitalization. Patients who were referred for screening colonoscopies during the same years were included as a control group. We compared the rates of diagnosis of CRC and advanced polyps for both groups before and after adjustment for multiple confounders. Moreover, we investigated risk factors that were associated with increased rate of advanced neoplasia diagnosis.A total of 350 patients were included in the AD group and 1502 patients in the screening colonoscopy control group. The CRC diagnosis rates (1.7% vs 0.3%; P = .09) and overall diagnosis rates of advanced neoplasia (12.3% vs 9.6%; P = .19) were not significantly different when findings were compared between the AD and control groups, respectively. Cases of complicated diverticulitis, however, were associated with increased risk of advanced neoplasia diagnosis (odds ratio (OR) 3.729, 95% confidence interval (CI) 1.803-7.713; P = .01).The diagnosis rate for advanced neoplasia after AD was not significantly different from that of average-risk populations. A course of complicated AD, however, was a potential risk factor.
Collapse
Affiliation(s)
- Fadi Abu Baker
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Mohanad Ganayem
- Department of internal medicine, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Amir Mari
- Department of Gastroenterology, Nazareth EMMS Hospital, Affiliated with the Faculty of Medicine, Bar Illan University
| | - Randa Taher
- Department of internal medicine, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Mohamad Suki
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Yael Kopelman
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| |
Collapse
|
|
40
|
Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
Collapse
Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
| |
Collapse
|
|
41
|
Ortenzi M, Williams S, Haji A, Ghiselli R, Guerrieri M. Acute Diverticulitis. EMERGENCY LAPAROSCOPIC SURGERY IN THE ELDERLY AND FRAIL PATIENT 2021:163-180. [DOI: 10.1007/978-3-030-79990-8_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
42
|
Sohn M, Agha A, Iesalnieks I, Tiefes A, Hochrein A, Friess H, Wilhelm D, Schorn S. Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis. BMJ Open 2020; 10:e042350. [PMID: 33384397 PMCID: PMC7780530 DOI: 10.1136/bmjopen-2020-042350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/23/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute diverticulitis of the sigmoid colon is increasingly treated by a non-operative approach. The need for colectomy after recovery from a flare of acute diverticulitis of the left colon, complicated diverticular abscess is still controversial. The primary aim of this study is to assess the risk of interval emergency surgery by systematic review and meta-analysis. METHODS AND ANALYSIS The systematic review and meta-analysis will be conducted in accordance to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE will be screened for the predefined searching term: (Diverticulitis OR Diverticulum) AND (Abscess OR pelvic abscess OR pericolic abscess OR intraabdominal abscess) AND (surgery OR operation OR sigmoidectomy OR drainage OR percutaneous drainage OR conservative therapy OR watchful waiting). All studies published in an English or German-speaking peer-reviewed journal will be suitable for this analysis. Case reports, case series of less than five patients, studies without follow-up information, systematic and non-systematic reviews and meta-analyses will be excluded. Primary endpoint is the rate of interval emergency surgery. Using the Review Manager Software (Review Manager/RevMan, V.5.3, Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration, 2012) meta-analysis will be pooled using the Mantel-Haenszel method for random effects. The Risk of Bias in Non-randomized Studies of Interventions tool will be used to assess methodological quality of non-randomised studies. Risk of bias in randomised studies will be assessed using the Cochrane developed RoB 2-tool. ETHICS AND DISSEMINATION As no new data are being collected, ethical approval is exempt for this study. This systematic review is to provide a new insight on the need for surgical treatment after a first attack of acute diverticulitis, complicated by intra-abdominal or pelvic abscesses. The results of this study will be presented at national and international meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020164813.
Collapse
Affiliation(s)
- Maximilian Sohn
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Ayman Agha
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Igors Iesalnieks
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | - Anna Tiefes
- Department of General-, Abdominal-, Endocrine- and Minimally Invasive Surgery, München Klinik Bogenhausen, Munchen, Germany
| | | | - Helmut Friess
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Dirk Wilhelm
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Stephan Schorn
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| |
Collapse
|
|
43
|
Nascimbeni R, Amato A, Cirocchi R, Serventi A, Laghi A, Bellini M, Tellan G, Zago M, Scarpignato C, Binda GA. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Tech Coloproctol 2020; 25:153-165. [PMID: 33155148 PMCID: PMC7884367 DOI: 10.1007/s10151-020-02346-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.
Collapse
Affiliation(s)
- R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25124, Brescia, Italy.
| | - A Amato
- Unit of Coloproctology, Department of Surgery, Borea Hospital, Sanremo, Italy
| | - R Cirocchi
- Department of Surgical and Medical Sciences, University of Perugia, Terni, Italy
| | - A Serventi
- Department of Surgery, Galliano Hospital, Acqui Terme, Italy
| | - A Laghi
- Department of Surgical-Medical Sciences and Translational Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - G Tellan
- Department of Internal, Anesthesiological and Cardiovascular Clinical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - C Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta
- Faculty of Medicine, Chinese University of Hong Kong, ShaTin, Hong Kong
| | - G A Binda
- General Surgery, Biomedical Institute, Genoa, Italy
| |
Collapse
|
|
44
|
Azhar N, Buchwald P, Ansari HZ, Schyman T, Yaqub S, Øresland T, Schultz JK. Risk of colorectal cancer following CT-verified acute diverticulitis: a nationwide population-based cohort study. Colorectal Dis 2020; 22:1406-1414. [PMID: 32301257 DOI: 10.1111/codi.15073] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
AIM Routine colonoscopy to exclude colorectal cancer (CRC) after CT-verified acute diverticulitis is controversial. This study aimed to compare the incidence of CRC in patients with acute diverticulitis with that in the general population. METHOD Patients with an emergency admission for diverticular disease to any Norwegian hospital between 1 January 2008 and 31 December 2010 were included through identification in the Norwegian Patient Registry using International Classification of Diseases (ICD-10) codes K57.1-9. To estimate the age-specific distribution of CT-verified acute uncomplicated diverticulitis (AUD) and acute complicated diverticulitis (ACD) in this nationwide study population, numbers from the largest Norwegian emergency hospital were used. Patients diagnosed with CRC within 1 year following their admission for acute diverticulitis were detected through cross-matching with the Cancer Registry of Norway. Based on both Norwegian age-specific incidence of CRC and estimated age-specific distribution of CT-verified diverticulitis, standard morbidity ratios (SMRs) were calculated. RESULTS A total of 7473 patients with emergency admissions for diverticular disease were identified (estimated CT-verified AUD n = 3523, ACD n = 1206); of these 155 patients were diagnosed with CRC within 1 year. Eighty had a CT-verified diverticulitis at index admission [41 AUD (51.3%); 39 ACD (49.7%)]. Compared with the general population, the SMR was 6.6 following CT-verified AUD and 16.3 following ACD, respectively. CONCLUSION In the first year after CT-verified acute diverticulitis, especially after ACD, the risk of CRC is higher than in the general population. This probably represents misdiagnosis of CRC as acute diverticulitis. Follow-up colonoscopy should be recommended to all patients admitted with acute diverticulitis.
Collapse
Affiliation(s)
- N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - P Buchwald
- Colorectal Unit, Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - H Z Ansari
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| | - T Schyman
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - S Yaqub
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - T Øresland
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - J K Schultz
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
|
45
|
Abstract
BACKGROUND Diverticular disease is of major clinical and health economic importance in Germany. Treatment recommendations in many international guidelines have changed significantly in recent years. The German national S2k guidelines are currently being revised. OBJECTIVE To summarize the most important clinical aspects in the management of diverticular disease from a surgical perspective. MATERIAL AND METHODS The recommendations were compiled based on current national and international guidelines and a selective literature search. RESULTS Acute uncomplicated diverticulitis without risk factors can be treated on an outpatient basis without antibiotics. For patients with complicated diverticulitis, hospital admission with parenteral antibiotic treatment is recommended. In the case of abscess formation >5 cm, percutaneous drainage can be performed. The indications for immediate sigmoid resection are free perforation and failure of conservative treatment. Elective resection is indicated in chronic recurrent diverticulitis with complications; all other indications are increasingly based on the individual quality of life of the patient. CONCLUSION Uncomplicated diverticulitis is increasingly being treated on an outpatient basis and without antibiotics. Apart from emergency settings, the indications for surgery are increasingly dependent on the quality of life. Elective sigmoid resection should be performed as laparoscopic surgery with primary anastomosis after obtaining results of computed tomography and total colonoscopy.
Collapse
|
|
46
|
Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020; 22 Suppl 2:5-28. [PMID: 32638537 DOI: 10.1111/codi.15140] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
AIM The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.
Collapse
Affiliation(s)
- J K Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - G A Binda
- Colorectal Surgery, BioMedical Institute, Genova, Italy
| | - G Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Biondo
- Department of General and Digestive Surgery - Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Chabok
- Colorectal Unit, Department of Surgery, Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S T van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Johanssen
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - W Kruis
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - D Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Post
- Mannheim Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - F Ris
- Division of Visceral Surgery, Geneva University hospitals and Medical School, Geneva, Switzerland
| | - T A Rockall
- Minimal Access Therapy Training Unit (mattu), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - A Samuelsson
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.,Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University Hospital of Varese, University of Insubria, Varese, Italy
| | - D Tartaglia
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - A Thorisson
- Department of Radiology, Västmanland's Hospital Västerås, Västerås, Sweden.,Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, Västerås, Sweden
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
| | - W Bemelman
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| |
Collapse
|
|
47
|
El Zanati H, Chen A, Attiya A, Leung E. Is routine colonoscopy necessary for patients who have an unequivocal computerised tomography diagnosis of acute diverticulitis? Scott Med J 2020; 66:11-15. [PMID: 32781909 DOI: 10.1177/0036933020949228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To assess the incidence of underlying colorectal malignancy in patients admitted as an emergency with a CT diagnosis of acute diverticulitis and determine the need for routine follow up colonoscopy. METHODS A retrospective study was performed on all patients who had been admitted to our surgical unit with CT diagnosed diverticulitis from September 2016 to September 2018 (n = 125). RESULTS 11 patients (8.8%) required emergency resection with no underlying malignancy found. 76 patients (61%) had a follow up colonoscopy after being discharged. 4 patients were found to have an underlying colorectal malignancy, one of them suspected on CT and another an incidentally detected caecal polyp cancer. Therefore 3/87(3.4%) had an unexpected cancer diagnosis and all those in the diseased segment were within complicated diverticulitis. CONCLUSION Nowadays, multi-slice CT scanners are so good at giving an accurate assessment of colonic pathology. In our study, 96.6% of the patients with a CT diagnosis of acute diverticulitis had no underlying malignancy in the diseased segment with all the cancers within complicated diverticulitis. With such a low yield of underlying malignancy in uncomplicated diverticulitis, we question the need for routine follow up colonoscopy when there is no CT suspicion of malignancy in these patients.
Collapse
Affiliation(s)
- Hisham El Zanati
- Specialty doctor in Surgery, General Surgery Department, University Hospital Crosshouse, UK
| | - Adriel Chen
- Foundation year 1 doctor, General Surgery Department, Hairmyres University Hospital, UK
| | - Abdulaziz Attiya
- Specialty doctor in surgery, General Surgery Department, Hairmyres University Hospital, UK
| | - Edward Leung
- Consultant general surgeon, General Surgery Department, University Hospital Crosshouse, UK
| |
Collapse
|
|
48
|
Abstract
There are several vascular ultrasound technologies that are useful in challenging diagnostic situations. New vascular ultrasound applications include directional power Doppler ultrasound, contrast-enhanced ultrasound, B-flow imaging, microvascular imaging, 3-dimensional vascular ultrasound, intravascular ultrasound, photoacoustic imaging, and vascular elastography. All these techniques are complementary to Doppler ultrasound and provide greater ability to visualize small vessels, have higher sensitivity to detect slow flow, and better assess vascular wall and lumen while overcoming limitations color Doppler. The ultimate goal of these technologies is to make ultrasound competitive with computed tomography and magnetic resonance imaging for vascular imaging.
Collapse
Affiliation(s)
- Lori Mankowski Gettle
- University of Wisconsin - Madison, 600 Highland Avenue, E3/380, Madison, WI 53792, USA.
| | - Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale New Haven Hospital, 330 Cedar Street, TE 2-214, New Haven, CT 06520, USA. https://twitter.com/MargaritaRevzin
| |
Collapse
|
|
49
|
Thorisson A, Nikberg M, Torkzad MR, Laurell H, Smedh K, Chabok A. Diagnostic accuracy of acute diverticulitis with unenhanced low-dose CT. BJS Open 2020; 4:659-665. [PMID: 32431087 PMCID: PMC7397358 DOI: 10.1002/bjs5.50290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background The aim of this study was to evaluate the diagnostic accuracy of unenhanced low‐dose CT (LDCT) in acute colonic diverticulitis in comparison with contrast‐enhanced standard‐dose CT (SDCT). Methods All patients with clinically suspected diverticulitis who underwent LDCT followed by SDCT between January and October 2017 were evaluated prospectively. CT examinations were assessed for signs of diverticulitis, complications and other differential diagnoses by three independent radiologists (two consultants and one fourth‐year resident) using SDCT as the reference method. Sensitivity and specificity were calculated and Cohen's κ coefficient was used for agreement analyses. Results Of the 149 patients included (mean age 66·7 years, M : F ratio 0·4), 107 (71·8 per cent) had imaging consistent with diverticulitis on standard CT. Sensitivity and specificity values for a diverticulitis diagnosis using LDCT were 95–99 and 86–100 per cent respectively, and respective values for identification of complications were 58–73 and 78–100 per cent. The corresponding κ values among the three readers for diagnosis were 0·984, 0·934 and 0·816, whereas κ values for complications were 0·680, 0·703 and 0·354. Of the 26 patients who presented with other causes of abdominal symptoms identified on standard CT, 23 were diagnosed correctly on LDCT. Missed cases included splenic infarction (1) and segmental colitis (2). Conclusion The diagnostic accuracy of LDCT was high for the presence of acute diverticulitis. However, as signs of complicated disease can be missed using the low‐dose protocol, use of LDCT as a primary examination method should not preclude SDCT when complications may be suspected.
Collapse
Affiliation(s)
- A Thorisson
- Department of Radiology, Västerås, Sweden.,Centre for Clinical Research Uppsala University, Västerås, Sweden
| | - M Nikberg
- Centre for Clinical Research Uppsala University, Västerås, Sweden.,Colorectal Unit, Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
| | - M R Torkzad
- Department of Diagnostic Radiology, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - H Laurell
- Colorectal Unit, Department of Surgery, Landstinget Dalarna, Mora, Sweden
| | - K Smedh
- Centre for Clinical Research Uppsala University, Västerås, Sweden.,Colorectal Unit, Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
| | - A Chabok
- Centre for Clinical Research Uppsala University, Västerås, Sweden.,Colorectal Unit, Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
| |
Collapse
|
|
50
|
Abstract
BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).
Collapse
|