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1.
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.2.
Background and objectives
Radiological imaging is of central importance for diagnosing acute and chronic diverticular disease. The indications for the various radiological imaging modalities and their most important findings are discussed in this review article.Methods
The current literature on this topic was reviewed and summarized.Results
Contrast-enhanced computed tomography of the abdomen is the method choice in cases of suspected acute diverticulitis and should enable a differentiation between complicated and uncomplicated forms. In suspected chronic diverticular disease virtual colonoscopy represents an equivalent alternative to classical colonoscopy.Conclusion
Based on imaging findings therapeutic decisions can be made and the radiological findings can have some prognostic value in the follow-up of patients.3.
Background
The prevalence of diverticulosis is between 28–45% in the general population and by more than 60% for those over 70 years old. A further increase in the hospitalization rate due to complications can be observed. Furthermore, younger patients are now also increasingly suffering from diverticulosis. It is time to question the non-critical use of antibiotic treatment as well as the necessity of surgery. New treatment approaches must be found.Objective
What significance does conservative treatment, especially antibiotic treatment, have in the treatment of diverticular disease?Methods
The current literature and the first S2k guidelines on “diverticular disease/diverticulitis” were evaluated.Results
There are several options in the primary prophylaxis of diverticular disease. A high-fiber, low-meat diet, physical activity and weight management as well as avoiding cigarettes can reduce complications. Avoiding non-steroidal anti-inflammatory drugs (NSAID), corticoids and opioids also reduces the risk of complications. As long as there are no risk factors, the use of antibiotics is not normally necessary in the treatment of acute uncomplicated diverticular disease. Aminosalicylates and non-resorbable antibiotics have not been proven to be effective. The treatment of acute complicated diverticulitis consists of antibiotics, infusion of electrolytes and, if necessary abscess drainage or surgery.Conclusion
The indications and correct selection of conservative treatment has to be determined by evaluation of the stage of diverticular disease, the physical condition and the patient’s risk factors. Antibiotic treatment is ultimately only one part of the conservative management.4.
Background
Patients with polycystic kidney disease (PKD) who have had a kidney transplant have an increased risk of diverticular disease and complicated diverticulitis. Literature is limited regarding the severity of diverticulitis in patients with PKD who have not had a transplant. We aim to assess whether patients with PKD, with and without renal transplant, have a similar course of diverticulitis.Methods
A retrospective review of all adult PKD patients at our institution diagnosed with diverticulitis between 2000 and 2016 was conducted. Patients without documented PKD and diverticulitis were excluded. We compared PKD patients with and without renal transplantation.Results
A total of 41 patients were identified. Mean age was 60 (± 12), and 56% were female. Fourteen patients had undergone renal transplantation. Five (19%) non-transplant patients had complicated diverticulitis, compared to 43% (n = 6) transplanted (p = 0.33). Fifteen (56%) non-transplant and 8 (57%) transplant patients had recurrent diverticulitis (p = 1.00). Three (11%) non-transplant and 5 (36%) transplanted patients had recurrent complicated diverticulitis. Eight (30%) non-transplant and 7 (50%) transplant patients underwent surgery (p = 0.31). All 8 non-transplant patients underwent sigmoid resection with primary anastomosis without diversion. In the transplant group, 3 Hartmann procedures and 1 sigmoid resection with and 3 without diversion were performed. There was one in-hospital death in each group.Conclusion
In our group of patients, there was no difference in rate of recurrent diverticulitis, diverticulitis complications, or operative intervention in patients with PKD with and without renal transplant. The renal transplant group had a higher rate of recurrent, complicated diverticulitis.5.
Rasmus Gregersen Kristoffer Andresen Jakob Burcharth Hans-Christian Pommergaard Jacob Rosenberg 《International journal of colorectal disease》2016,31(5):983-990
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.6.
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.7.
N. Horesh Y. Saeed H. Horesh Y. Berger C. Speter R. Pery D. Rosin M. Gutman O. Zmora 《Techniques in coloproctology》2016,20(6):383-387
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 50.8.
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.9.
Background
Laparoscopic sigmoidectomy is the gold standard for elective surgical treatment of diverticulitis. A periumbilical single-port technique reduces the size of the access wound, usually to 3–4 cm. However, in the presence of large phlegmon or fistulae, the risk of conversion is higher and the extraction site might be enlarged. A suprapubic Pfannenstiel incision reduces the risk of incisional hernia compared to umbilical access and might provide the possibility to perform sigmoidectomy with a hybrid technique. The aim of the present study was to investigate the feasibility of laparoscopic sigmoidectomy through a single suprapubic transverse access for large diverticular phlegmon.Methods
Consecutive patients with a diverticular inflammatory mass?≥?5 cm, with or without sigmoid-vesical fistula, were considered candidates for laparoscopic sigmoidectomy through a 5-cm single-port suprapubic (SPSP) access, extended (if required) to match the size of the inflammatory mass.Results
Twenty patients underwent SPSP sigmoidectomy at our institution in April 2014–April 2017. All procedures were completed by SPSP access, with no intraoperative complications or need for additional trocar placement. Eight patients had a sigmoid-vesical fistula (bladder sutured in three patients). The splenic flexure was mobilized in nine patients. Median operative time was 178 min and median hospital stay was 5.5 days (iqr 4–6). Postoperative complications occurred in four patients and included one subcutaneous hematoma, one urinary tract infection, and two superficial wound infections. After a median follow-up time of 25 months (interquartile range 15–38), all patients experienced complete resolution of symptoms, with no incisional hernias reported.Conclusions
SPSP sigmoidectomy for diverticulitis is feasible and effective, minimizing the size of the access wound and avoiding increased risk of hernia. This approach might be especially valuable for the management of large diverticular phlegmon and sigmoid-vesical fistula.10.
Purpose
To evaluate the impact of superior rectal artery (SRA) sparing technique on anastomotic leakage in laparoscopic sigmoidectomy for diverticular disease.Material and methods
A retrospective multicenter analysis of all patients undergoing laparoscopic sigmoid resection for diverticular disease between 2002 and 2015 was conducted. Data were recorded in three hospitals: University Hospital Regensburg, Marienhospital Gelsenkirchen, and Städtisches Klinikum München Bogenhausen. The SRA was resected between 2002 and 2005. Since 2005, the artery was preserved in most cases.Results
Two hundred sixty-seven patients were included. One hundred sixty patients presented with complicated diverticulitis (60%). The SRA was resected in 102 patients (group 1) and preserved in 157 patients (group 2, no data in eight cases). Anastomotic leakage occurred in 7% of patients in group 1 and 1.9% of patients in group 2 (p = 0.053). Duration of surgery was significantly shorter (157 vs. 183 min, p < 0.001) in group 2 patients. Length of hospital stay was without significant difference (group 1 8.2 days; group 2 8.3 days; p = 0.83). The conversion rate was higher in group 2 patients; however, the difference was not statistically significant (9 vs. 3%, p = 0.07). There was no significant difference between both groups regarding intraoperative complications and overall complication rate. The length of the resected specimen (19 vs. 21 cm, p = 0.001) was significantly shorter in group 2 patients.Conclusion
Preservation of the SRA seems to be associated with favorable outcome in patients undergoing laparoscopic sigmoid resection for diverticular disease.11.
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.12.
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.13.
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.14.
Dima Saab Rosane Nisenbaum Irfan Dhalla Stephen W. Hwang 《Journal of general internal medicine》2016,31(9):1011-1018
BACKGROUND
Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations.OBJECTIVE
The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness.DESIGN
We conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort.PARTICIPANTS
This study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005.MAIN MEASURES
The primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital.KEY RESULTS
Between 6 December 2004 and 31 March 2009, homeless participants (N?=?203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR?=?3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR?=?2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR?=?1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission.CONCLUSIONS
Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population.15.
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.16.
Purpose
Diverticular disease increased steadily concomitant with elevated rates of overweight and obesity during the 20th century. Therefore, the objective of this study was to investigate whether overweight and obesity in midlife predict future diverticular disease in men.Methods
This was a prospective cohort study of a general population of men living in Göteborg, Sweden. A community-based sample of 7,494 men, investigated when aged 47 to 55 years, were followed from baseline in 1970 to 1973 for a maximum of 28 years. Hospitalization with a discharge diagnosis of diverticular disease according to the Swedish hospital discharge register was measured.Results
Totally, 112 men (1.5 percent) were hospitalized with diverticular disease. A relationship between body mass index and diverticular disease was demonstrated; men with a body mass index between 20 and 22.5 kg/m2 had the lowest risk. After adjustment for covariates, the risk increased linearly in men who had a body mass index of 22.5 to 25 (multiple-adjusted hazard ratio, 2.3; 95 percent confidence interval, 0.9–6; 25–27.5 (hazard ratio, 3 (1.2–7.6)), 27.5–30 (hazard ratio 3.2, (1.2–8.6)), and 30 or greater (hazard ratio 4.4, (1.6–12.3)) kg/m2 (P for linear trend?=?0.004). Men with a body mass index of ≤20 kg/m2 had a nonsignificantly elevated risk (hazard ratio, 3 (0.7–12.5)). Smoking (hazard ratio, 1.6 (1.1–2.3) and diastolic blood pressure (hazard ratio, 1.02 (1.01–1.04) per mmHg) also were independently related to risk of diverticular disease.Conclusions
In a large community-based sample of middle-aged men, overweight and obesity were strongly linked to future severe diverticular disease leading to hospitalization.17.
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.18.
M. Sohn A. Agha W. Heitland F. Gundling P. Steiner I. Iesalnieks 《Techniques in coloproctology》2016,20(8):577-583
Background
The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy.Methods
All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24–48 h later At this point a choice was made between anastomosis and Hartmann’s procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann’s procedure) at the initial operation.Results
Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (p = 0.66).Conclusions
Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.19.
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.20.