Sigmoid resection for diverticulitis is more difficult than for malignancies

Purpose

Sigmoid resection for diverticulitis is usually the first procedure performed when starting the learning process for laparoscopic colorectal surgery. The aim of this study is to evaluate the difficulty of laparoscopic sigmoid resection for diverticulitis in comparison to sigmoid malignancy in order to assess its role in the residents training program.

Methods

A cohort of patients was selected who suffered either from malignancy or recurrent diverticulitis in the sigmoid colon. Laparoscopic sigmoid resection was performed. The degree of difficulty was assessed by intraoperative complications and intraoperative technical challenges. Furthermore, take-overs from assistant to surgeon, surgeon to surgeon, and conversion were reported.

Results

A total of 224 patients were included, 119 (53.1%) men and 105 (46.9%) women.Patients suffering from diverticulitis had significantly less co-morbidities than those with malignancies. In the diverticulitis group, there were significantly more technical challenges. There was a higher rate in take-overs from residents (p = 0.02) as well as surgeon to surgeon (p = 0.04). The rate of conversions was also significantly higher in the diverticulitis group (p = 0.03) when compared to the malignancy group.

Conclusions

The outcomes of our study show that diverticulitis may not be the ideal condition to start the learning process for laparoscopic colorectal surgery.

     

Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain,a receiver operating characteristic curve analysis

Purpose

The study investigated the capability of clinical findings, temperature, C-reactive protein (CRP), and white blood cell (WBC) count to discern patients with acute colonic diverticulitis from all other patients admitted with acute abdominal pain.

Methods

The probability of acute diverticulitis was assessed by the examining doctor, using a scale from 0 (zero probability) to 10 (100 % probability). Receiver operating characteristic (ROC) curves were used to assess the clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain.

Results

Of 833 patients admitted with acute abdominal pain, 95 had acute colonic diverticulitis. ROC curve analysis gave an area under the ROC curve (AUC) of 0.95 (CI 0.92 to 0.97) for ages <65 years, AUC = 0.86 (CI 0.78 to 0.93) in older patients. Separate analysis showed an AUC = 0.83 (CI 0.80 to 0.86) of CRP alone. White blood cell count and temperature were almost useless to discriminate acute colonic diverticulitis from other types of acute abdominal pain, AUC = 0.59 (CI 0.53 to 0.65) for white blood cell count and AUC = 0.57 (0.50 to 0.63) for temperature, respectively.

Conclusion

This prospective study demonstrates that standard clinical evaluation by non-specialist doctors based on history, physical examination, and initial blood tests on admission provides a high degree of diagnostic precision in patients with acute colonic diverticulitis.

     

Asian patients with Hinchey Ia acute diverticulitis: a condition for the ambulatory setting?

Background

Diverticulitis in Asians is a different disease entity from Western counterparts. Few Asian studies have evaluated the management of acute Hinchey Ia diverticulitis with consideration for outpatient management. The purpose of this study was to evaluate the outcomes of Asian patients with Hinchey Ia acute diverticulitis.

Methods

A retrospective review of all patients who were treated for Hinchey Ia acute colonic diverticulitis between 2012 and 2014 was performed. All patients were diagnosed on computed tomography (CT).

Results

There were 129 patients with Hinchey Ia acute diverticulitis. Fifty-five (42.6%) patients were male, and the median age was 54 years (range, 30–86). Eighty-seven (67.4%) patients had right-sided diverticulitis.Most patients were treated empirically with intravenous ceftriaxone and metronidazole (89.1%). They were then discharged with oral antibiotics. Only 6.1% of patients had a positive blood culture. The median length of stay in the hospital was 4 (range, 3–4) days.Only three (2.3%) patients were readmitted for acute diverticulitis within 30 days. They were managed with antibiotics and discharged well. The repeated CT scans reconfirmed Hinchey Ia diverticulitis. No patients required emergency surgery, and there were no 30-day mortalities.

Conclusion

Asian patients with Hinchey Ia diverticulitis recovered well with conservative management and could be amenable to outpatient therapy. Future prospective studies should be performed amongst Asians to evaluate managing this condition in an ambulatory setting.

     

Colonoscopy after the first episode of acute diverticulitis: challenging management paradigms

Background

Colonoscopy is commonly recommended after the first episode of acute diverticulitis to exclude colorectal neoplasia. Recent data have challenged this paradigm due to insufficient diagnostic yield. The aim of this study was to assess whether colonoscopy after the first episode of acute diverticulitis is needed to exclude colorectal neoplasia.

Methods

We performed a retrospective cohort analysis of medical records of patients admitted for the first episode of acute diverticulitis between January 2008 and December 2012. Ambulatory colonoscopy was routinely recommended at discharge. Clinical follow-up and telephone surveys were used for data collection.

Results

Four hundred and twenty-five patients with a mean age of 62.6 years (range 21–98 years) were admitted during the 5-year period. Three hundred and ten (72.9 %) patients underwent colonoscopy at median time of 3.2 months after discharge. Five patients (1.6 %) of the 310 available for evaluation had malignant findings in colonoscopy. Of those, one patient had rectal carcinoma away from the inflamed site and one had colonic lymphoma. None of the 95 patients <50 years of age was found to have adenocarcinoma of the colon.

Conclusions

Cancer is rarely detected in colonoscopy following the first episode of acute diverticulitis. These results question this indication for colonoscopy, especially in patients under 50.

     

Short-term mortality,readmission, and recurrence in treatment of acute diverticulitis with abscess formation: a nationwide register-based cohort study

Purpose

The aim of the study was to investigate short-term mortality, readmission, and recurrence in a national cohort of patients with Hinchey Ib-II diverticulitis.

Methods

The retrospective cohort-investigation was conducted using a database consisting of the entire Danish population (n?=?6,641,672) in year 2000–2012, formed by linking the Danish Registers. Patients admitted with acute Hinchey Ib-II diverticulitis were identified from ICD-10 discharge codes and stratified according to treatment into an operative, drainage, and antibiotics group. The primary outcome was 30-day mortality from admission, secondary outcomes were mortality, readmission, and recurrence within 30 days post-discharge. The study was reported using RECORD guidelines.

Results

A total of 3148 eligible patients were identified. The cohort had a mean age of 65.1 year, 25.6 % had previously been admitted with diverticulitis, and 48.1 % had registered comorbidities. Within 30 days from admission, 8.7 % of the patients died. Of patients discharged, 2.5 % died, 23.8 % was readmitted, and 5.9 % was readmitted due to diverticulitis within 30 days from discharge. In multivariate analyses, increasing age was associated with mortality at odds-ratio (95 % CI) 1.10 (1.09–1.12). Previous complicated and uncomplicated diverticulitis reduced mortality with odds-ratio 0.50 (0.33–0.76) and 0.73 (0.58–0.92), while uncomplicated diverticulitis also increased risk of recurrence with odds-ratio 1.51 (1.24–1.84). Glucocorticoid usage was associated with mortality with odds-ratio 1.49 (1.23–1.81) and readmission with odds-ratio 2.91 (1.24–6.80).

Conclusion

Acute diverticulitis with abscess formation is a severe and life-threatening condition. Direct comparisons of treatment groups were not possible due to possible confounding by indication.

     

Selective association of nonaspirin NSAIDs with risk of diverticulitis

Purpose

The purpose of this study is to investigate the association of intake of nonsteroidal anti-inflammatory drugs (NSAIDs) and in particular nonaspirin NSAIDs and compare it with other risk factors for the progression of diverticulosis to diverticulitis in patients who underwent colonoscopy.

Methods

A total of 194 patients who underwent complete colonoscopy in our center between 2012 and 2016 were recruited: 144 with diverticulosis without prior diverticulitis (median age 71 years, 59.7% men) and 50 with diverticulitis (median age 64 years, 54.0% men). Data concerning current and previous medication as well as concomitant diseases were collected using a structured questionnaire and by revision of patients medical charts.

Results

Patients with diverticulitis were significantly (p?<?0.001) younger as compared to individuals with plain diverticulosis (median age 64 versus 71 years, respectively). The intake of NSAIDs significantly (p?=?0.002) increased the risk of prior diverticulitis (OR 3.2, 95% CI 1.5–6.9). In the multivariate model, both age (p?<?0.001) and NSAIDs (p?=?0.03) proved to be independent determinants of diverticulitis. When analyzing aspirin intake, it was not associated with diverticulitis.

Conclusions

Our study demonstrates, in line with previous reports, that intake of NSAIDs is associated with diverticulitis. We show in particular that nonaspirin NSAIDs might be selectively associated with diverticulitis. These results point to divergent role of aspirin and nonaspirin NSAIDs in the development of diverticulitis.

     

Emergency admissions for complicated colonic diverticulitis are increasing: a nationwide register-based cohort study

Background

Acute colonic diverticulitis is common in the Western world representing a growing burden on health care. We aimed to report the factual epidemiological and demographic characteristics in patients with acute diverticulitis in a large nationwide population.

Method

We conducted a population-based cohort study from 2000 to 2012 on the complete Danish population, which included all patients with acute colonic diverticulitis. Data were composed through two national longitudinal registries. The study main outcomes were demographic development regarding hospital admission, age, gender, geographical residency, and seasonal information.

Results

A total of 101,963 acute hospital contacts were identified from 2000 to 2012, of these 44,160 were due to acute diverticulitis. From 2000 to 2012, overall admission rates for complicated diverticulitis increased significantly with 42.7%. There was a small increase in hospital admissions due to acute diverticulitis, and uncomplicated diverticulitis accounted for 83–88% of all admissions. No significant development was seen in cases of uncomplicated diverticulitis. The majority of patients were older than 50 years (85%) and 60% were women. The male gender dominated in patients younger than 50 years (58%), whereas women dominated above 50 years (63%). Mean age and dominating age group decreased significantly from 2000 to 2012 for both genders. A significantly larger proportion of male patients had complicated diverticulitis than uncomplicated diverticulitis. Most admissions were seen during autumn.

Conclusion

We found that acute colonic diverticulitis has been progressing over the last decade with more severe cases of disease. Our findings underline the need for further research to identify the relevant risk factors and causal circumstances.

     

Association between diverticular disease and Ehlers-Danlos syndrome: a 13-year nationwide population-based cohort study

Purpose

The aim of this study was to examine occurrence and consequences of diverticular disease in patients with Ehlers-Danlos syndrome (EDS) compared with a matched cohort.

Methods

This nationwide population-based cohort study was conducted using data from medical registers in Denmark from year 2000 to 2012. The EDS cohort was identified using the specific diagnosis code for EDS and was randomly matched in a ratio of 1:20 by sex and date of birth (±1 year) with persons from the Danish general population. The occurrence of diverticular disease and the clinical characteristics of the initial diverticular event were compared between the EDS cohort and the comparison cohort. The first admission with diverticulitis was identified, and severity of diverticulitis, treatment, colonoscopies, length of stay, and 30-day mortality were investigated.

Results

We identified 1336 patients with EDS and matched a control cohort of 26,720 patients. The occurrence of diverticular disease in the EDS cohort (2.0 %) and the comparison cohort (0.68 %) differed significantly (p < 0.001). At the first diverticular event, the majority of patients were women (85 % for EDS and 87 % for the comparison cohort). Mean age, localization, and type of contact did not differ significantly. Admission with diverticulitis (1.0 % for EDS and 0.34 % for the comparison cohort) differed significantly (p < 0.001). We found no significant difference in severity of diverticulitis, treatment, length of stay, or 30-day mortality between the EDS and the comparison cohorts.

Conclusions

Patients with EDS had an increased occurrence of overall diverticular events and admissions with diverticulitis compared with the general population.

     

Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis

Purpose

Since outpatient treatment and omitting antibiotics for uncomplicated acute colonic diverticulitis have been proven to be safe in the majority of patients, selection of patients that may not be suited for this treatment strategy becomes an important topic. The aim of this study is to identify computed tomography (CT) imaging predictors for a complicated disease course of initially uncomplicated acute diverticulitis.

Methods

CT imaging from a randomized controlled trial (DIABOLO study) of an observational vs. antibiotic treatment strategy of first-episode uncomplicated acute diverticulitis patients was re-evaluated. For each patient that developed complicated diverticulitis within 90 days after randomization, two patients with an uncomplicated disease course were randomly selected. Two abdominal radiologists, blinded for outcomes, independently re-evaluated all CTs.

Results

Of the 528 patients in the DIABOLO trial, 16 patients developed complications (abscess > 5 cm, perforation, bowel obstruction) within 90 days after randomization. In the group with a complicated course of initially uncomplicated diverticulitis, more patients with fluid collections (25 vs. 0%; p = 0.009) and a longer inflamed colon segment (86 ± 26 mm vs. 65 ± 21 mm; p = 0.007) were observed compared to an uncomplicated course of disease. Pericolic extraluminal air was no predictive factor.

Conclusion

Fluid collections and to a lesser extent the length of the inflamed colon segment may serve as predictive factors on initial CT for a complicated disease course in patients with uncomplicated acute colonic diverticulitis. These findings may aid in the selection of patients not suitable for outpatient treatment and treatment without antibiotics.

     

Elektive Operationsindikationen bei Sigmadivertikulitis

Background

A paradigm shift in therapeutic management of sigmoid diverticulitis has occurred with increasing reluctance regarding surgical treatment. While there is still a clear surgical indication in cases of complications such as strictures, fistulas, perforations or persistent bleeding, an elective indication for sigmoid resection is not clearly defined, especially in chronic-recurrent courses.

Objectives

The main aspects of elective surgery for sigmoid diverticulitis are discussed.

Materials and methods

Relevant studies were selected and the reference lists from those studies were also searched.

Results

An uncomplicated form of acute diverticulitis (Classification of Diverticular Disease [CDD] type 1a/b) is not an indication for surgery (exception: immunosuppressed patients). In acute complicated diverticulitis (except free perforation), elective surgery should only be recommended in case of a macroabscess (CDD type 2b). In chronic recurrent, uncomplicated diverticulitis (CDD typ 3a/b), indication for surgery should be individualized. However, indications for elective surgery are complications such as strictures or fistulas (CDD type 3c). Recent data show that patients with type 2b and 3 diverticulitis benefit from elective surgery, especially in terms of quality of life.

Conclusions

Although the majority of patients with diverticulitis can be treated conservatively, elective surgery should also be considered in terms of better quality of life compared to conservative therapy.

     

Low risk of complications in patients with first-time acute uncomplicated diverticulitis

Purpose

First-time acute uncomplicated diverticulitis (AUD) has been considered to have an increased risk of complication, but the level of evidence is low. The aim of the present study was to evaluate the risk of complications in patients with first-time AUD and in patients with a history of diverticulitis.

Methods

This paper is a population-based retrospective study at Västmanland’s Hospital, Västerås, Sweden, where all patients were identified with a diagnosis of colonic diverticular disease ICD-10 K57.0–9 from January 2010 to December 2014. The records of all patients were surveyed and patients with a computed tomography (CT)-verified AUD were included. Complications defined as CT-verified abscess, perforation, colonic obstruction, fistula, or sepsis within 1 month from the diagnosis of AUD were registered.

Results

Of 809 patients with AUD, 642 (79%) had first-time AUD and 167 (21%) had a previous history of AUD with no differences in demographic or clinical characteristics. In total, 16 (2%) patients developed a complication within 1 month irrespective of whether they had a previous history of diverticulitis (P = 0.345). In the binary logistic regression analysis, first-time diverticulitis was not associated with increased risk of complications (OR 1.58; CI 0.52–4.81). The rate of antibiotic therapy was about 7–10% during the time period and outpatient management increased from 7% in 2010 to 61% in 2014.

Conclusions

The risk for development of complications is low in AUD with no difference between patients with first-time or recurrent diverticulitis. This result strengthens existing evidence on the benign disease course of AUD.

     

Nonoperative management of perforated acute diverticulitis with extraluminal air: results and risk factors of failure

Aim

The aim of this study was to analyze the results of nonoperative management of patients with perforated acute diverticulitis with extraluminal air and to identify risk factors that may lead to failure and necessity of surgery.

Methods

Methods included observational retrospective cohort study of patients between 2010 and 2015 with diagnosis of diverticulitis with extraluminal air and with nonoperative management initial. Patient demographics, clinical, and analytical data were collected, as were data related with computed tomography. Univariate and multivariate analyses with Wald forward stepwise logistic regression were performed to analyze results and to identify risk factors potentially responsible of failure of nonoperative management.

Results

Nonoperative management was established in 83.12% of patients diagnosed with perforated diverticulitis (64 of 77) with an overall success rate of 84.37%, a mean hospital stay of 11.98 ± 7.44 days and only one mortality (1.6%). Patients with pericolic air presented a greater chance of success (90.2%) than patients with distant air (61.5%). American Society of Anesthesiologists (ASA) grade III-IV (OR, 5.49; 95% CI, 1.04–29.07) and the distant location of air (OR, 4.81; 95% CI, 1.03–22.38) were the only two factors identified in the multivariate analysis as risk factors for a poor nonoperative treatment outcome. Overall recurrence after conservative approach was 20.4%; however, recurrence rate of patients with distant air was twice than that of patients with pericolic air (37.5 vs 17.39%). Only 14.8% of successfully treated patients required surgery after the first episode.

Conclusion

Nonoperative management of perforated diverticulitis is safe and efficient. Special follow-up must be assumed in patients ASA III-IV and with distant air in CT.

     

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

Purpose

Optimal timing of surgery for acute diverticulitis remains unclear. A non-operative approach followed by elective surgery 6-week post-resolution is favored. However, a subset of patients fail on the non-operative management during index admission. Here, we examine patients requiring emergent operation to evaluate the effect of surgical delay on patient outcomes.

Methods

Patients undergoing emergent operative intervention for acute diverticulitis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Primary endpoints of 30-day overall morbidity and mortality were evaluated via univariate and multivariate analysis.

Results

Of the 2,119 patients identified for study inclusion, 57.2 % (n = 1212) underwent emergent operative intervention within 24 h, 26.3 % (n = 558) between days 1–3, 12.9 % (n = 273) between days 3–7, and 3.6 % (n = 76) greater than 7 days from admission. End colostomy was performed in 77.4 % (n = 1,640) of cases. Unadjusted age and presence of major comorbidities increased with operative delay. Further, unadjusted 30-day overall morbidity, mortality, septic complications, and post-operative length of stay increased significantly with operative delay. On multivariate analysis, operative delay was not associated with increased 30-day mortality but was associated with increased 30-day overall morbidity.

Conclusions

Hartmann’s procedure has remained the standard operation in emergent surgical management of acute diverticulitis. Delay in definitive surgical therapy greater than 24 h from admission is associated with higher rates of morbidity and protracted post-operative length of stay, but there is no increase in 30-day mortality. Prospective study is necessary to further answer the question of surgical timing in acute diverticulitis.

     

The predictors of post-transplant coronary events among liver transplant recipients

Background/purpose

Cardiac morbidities can occur during the peri- and post-liver transplant (LT) period, affecting the long-term survival. The purpose of this study was to identify the potential factors that predict a coronary event post-transplantation.

Methods

Medical records of patients who underwent liver transplantation at Johns Hopkins Hospital between 2009 and 2013 were retrospectively reviewed. We looked at pre-liver transplant cardiac risk factors and the diagnostic tests utilized for coronary artery disease screening. Patients with and without post-liver transplant coronary events were compared.

Results

There were a total of 146 patients with a mean age at LT of 55.3 years. The prevalence of hypertension, tobacco use and diabetes within the patient population was 61.6 % (n = 90), 39 % (n = 57) and 37.6 % (n = 55), respectively. There were 29 deaths and 30 coronary events over a median follow-up period of 1.75 years. Age at the time of liver transplant was predictive of coronary event (OR 1.11, CI 1.01–1.20). The 1-year survival in patients with a coronary event was 47 versus 94 % in patients without a coronary event. The combined use of a dobutamine stress echocardiogram and coronary artery calcium score predicted a coronary event with a sensitivity of 62.5 % and specificity of 66.7 %.

Conclusion

In conclusion, LT recipients with cardiac events had limited survival as compared to the cohort without coronary events. Identification of such patients with noninvasive screening may provide a practical alternative to an invasive cardiac workup. Further improvement in screening strategies may minimize the liver transplant cardiac morbidity.

     

Perforated diverticulitis: is the right and left difference present here too?

Background

It is unclear if location of disease matters in perforated diverticulitis. Management guidelines for perforated diverticulitis currently do not make a distinction between right perforated diverticulitis (RPD) and left perforated diverticulitis (LPD). We aim to compare disease presentation and management outcomes between RPD and LPD.

Methods

This was a 10-year retrospective comparative cohort study of 99 patients with acute perforated diverticulitis between 2004 and 2013 in a single institution. Patients were divided into RPD and LPD groups based on location of disease and compared. Disease presentation was compared using modified Hinchey classification. Management outcomes assessed were failure of therapy, length of stay, mortality, surgical complications, and disease recurrence. Univariate analysis was performed using Student’s t test and χ² test where appropriate.

Results

RPD patients were younger (45.7?±?16.1 versus 58.3?±?14.7 years) and presented with lower modified Hinchey stage and no Hinchey IV diverticulitis when compared to LPD (14.3% Hinchey III versus 44.0% Hinchey III or IV). Conservative management of Hinchey I and II RPD and LPD was similarly successful (96.1 versus 96.5%), although RPD patients had shorter inpatient stay (4.6?±?2.2 versus 6.3?±?3.8 days) and less disease recurrence (3.1 versus 17.9%). Ten (20.4%) Hinchey I and II RPD patients were initially misdiagnosed with appendicitis and underwent surgery.

Conclusion

LPD is a more aggressive disease presenting with greater clinical severity in older patients and is associated with frequent disease recurrence when treated conservatively. Misdiagnosis of RPD as appendicitis is common and may lead to unnecessary surgery.

     

Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone

Purpose

Antibiotic treatment is the treatment of choice for uncomplicated diverticulitis (uD) and can be performed for mild complicated diverticulitis (mcD). In several cases, outpatient treatment (OT) can be undertaken. This study assessed the 1-month failure rate of OT for uD/mcD compared to inpatient treatment (IT), and identified predictive factors for treatment failure.

Methods

All consecutive patients (2006–2012) diagnosed with uD/mcD by CT scan were retrospectively analyzed. Acute uD was defined as absence of the following: abscess, fistula, extraluminal contrast, pneumoperitoneum, and need for immediate percutaneous drainage/surgery. Acute mcD was defined as complicated diverticulitis with abscess <4 cm or pneumoperitoneum <2 cm. All patients received antibiotherapy. Treatment failure was defined as (re)hospitalization the first month after treatment onset or need of drainage/surgery during hospitalization. All patients were contacted using a standardized questionnaire.

Results

Out of 540 uD/mcD, IT was offered to 369 patients (68%) and OT to 171 patients (32%). The IT group had higher median age, more women, higher median Charlson Index, more severe median Ambrosetti score, longer median time in the emergency room, and higher median CRP. Response rates to the questionnaire were 56% (IT) vs. 62% (OT), p = 0.18. Failure rates were 32% in IT vs. 10% in OT group, p < 0.01. Among the uD/mcD patients, admission/CT time between midnight and 6 AM, Ambrosetti score of 4, and free air around the colon were risk factors for failure.

Conclusions

Outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe. Prognostic factors of failure necessitating closer follow-up were admission/CT time, Ambrosetti score of 4, and free air around the colon.

     

Diverticulitis recurrence after percutaneous abscess drainage

Purpose

Recurrent diverticulitis has been reported in 30–50% of patients who recover from an episode of diverticular-associated abscess. Our aim was to review the outcomes of patients who underwent non-operative management after percutaneous drainage (PD) of colonic diverticular abscess.

Methods

All patients with a diverticular-associated abscess were identified between 2001 and 2012. Individual charts were queried for peri-procedural data and follow-up. The most recent follow-up data were acquired via the electronic medical record or telephone call.

Results

A total of 165 patients underwent PD of diverticular-associated abscesses. Abscess locations were pelvic (n = 122), abdominal (n = 36), and both (n = 7), while median abscess size was 6.1 ± 2.2 cm. One hundred eighteen patients clinically improved following non-operative management, and 81 of these patients did not undergo subsequent colonic resection within 4 months of PD. Of these, 8 died within 12 months. Among the remaining 73 patients, there were no significant differences in demographics or abscess variables compared to those who underwent elective surgery within 4 months. Only 7 of 73 patients had documented episodes of recurrences, while 22 patients later had elective surgery (1.1 ± 1.2 years from the index case). Five-year colectomy-free survival was 55% (95%CI 42–66%), while the recurrence-free survival at 5 years was 77% (95%CI 65–86%). All recurrences were managed non-operatively initially and one patient went on to have elective resection.

Conclusion

A sizable number of patients successfully recover from complicated diverticulitis following PD. Subsequent non-operative management carries an acceptable risk for recurrent episodes and may be considered as a reasonable management option.

     

Metachronous colorectal cancer

Aim

In this study, we present our patients with metachronous colorectal cancer.

Patients and methods

In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.

Results

Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months).

Conclusion

Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

     

Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients

Purpose

This prospective study aimed to compare outcomes after laparoscopic peritoneal lavage (LPL) and sigmoid resection with primary colorectal anastomosis (RPA).

Methods

From June 2010 to June 2015, 40 patients presenting with Hinchey III peritonitis from perforated diverticulitis underwent LPL or RPA. Patients with Hinchey II or IV peritonitis and patients who underwent an upfront Hartmann procedure were excluded. Primary endpoint was overall 30-day or in-hospital postoperative morbidity after surgical treatment of peritonitis.

Results

Twenty-five patients underwent RPA and 15 LPL. Overall postoperative morbidity and mortality rates were not significantly different after RPA and LPL (40 vs 67 %, p = 0.19; 4 vs 6.7 %, p = 1, respectively). Intra-abdominal morbidity and reoperation rates were significantly higher after LPL compared to RPA (53 vs 12 %, p < 0.01; 40 vs 4 %, p = 0.02, respectively). Multivariate analysis showed that LPL (p = 0.028, HR = 18.936, CI 95 % = 1.369–261.886) was associated with an increased risk of postoperative intra-abdominal septic morbidity. Among 6 patients who underwent reoperation after LPL, 4 had a Hartmann procedure. All surviving patients who had a procedure requiring stoma creation underwent stoma reversal after a median delay of 92 days after LPL and 72 days after RPA (p = 0.07).

Conclusion

LPL for perforated diverticulitis is associated with a high risk of inadequate intra-abdominal sepsis control requiring a Hartmann procedure in up to 25 % of patients. RPA appears to be safer and more effective. It may represent the best option in this context.

     

Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis—a meta-analysis

Purpose

Perforated diverticulitis often requires surgery with a colon resection such as Hartmann’s procedure, with inherent morbidity. Recent studies suggest that laparoscopic lavage may be an alternative surgical treatment. The aim of this study was to compare re-operations, morbidity, and mortality as well as health economic outcomes between laparoscopic lavage and colon resection for perforated purulent diverticulitis.

Methods

PubMed, Cochrane, Centre for Reviews and Dissemination, and Embase were searched. Published randomized controlled trials and prospective and retrospective cohorts with laparoscopic lavage and colon resection as interventions were identified. Trial limitations were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Re-operations, complications at 90 days classified according to Clavien-Dindo and mortality were extracted.

Results

Three randomized trials published between 2005 and 2015 were included in the analysis. The studies included a total of 358 patients with 185 patients undergoing laparoscopic lavage. At 12 months, the relative risk of having a re-operation was lower for laparoscopic lavage compared to colon resection in the two trials that had a 12 month follow-up. We found no significant differences in Clavien-Dindo complications classified more than level IIIB or mortality at 90 days.

Conclusions

The risk for re-operations within the first 12 months after index surgery was lower for laparoscopic lavage compared to colon resection, with overall comparable morbidity and mortality. Furthermore, Hartmann’s resection was more costly than laparoscopic lavage. We therefore consider laparoscopic lavage a valid alternative to surgery with resection for perforated purulent diverticulitis.