Surgical treatment of acute recurrent diverticulitis: early elective or late elective surgery. An analysis of 237 patients

Background  

The optimal timing of elective surgery in diverticulitis remains unclear. We attempted to investigate early elective versus late elective laparoscopic surgery in acute recurrent diverticulitis in a retrospective study.     

Acute and Elective Laparoscopic Resection for Complicated Sigmoid Diverticulitis: Clinical and Histological Outcome

Background

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

Methods

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

Results

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

Conclusions

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.     

Outcomes of Laparoscopic Versus Open Colectomy in Elective Surgery for Diverticulitis

Background  

The role of laparoscopy in the management of diverticular disease is evolving. Concerns were raised in the past because laparoscopic resection for diverticulitis is often difficult and occasionally hazardous. This study was undertaken to evaluate the difference in overall outcomes between elective open and laparoscopic surgery with or without anastomosis for diverticulitis.     

The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis

Backround  

Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.     

The Evolving Role of Laparoscopy in Colonic Diverticular Disease: A Systematic Review

Background

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

Results

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

Conclusions

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.     

Laparoscopic sigmoidectomy in moderate and severe diverticulitis: analysis of short-term outcomes in a continuous series of 121 patients

Background

The role of laparoscopic surgery has been shown to be safe, feasible, and equivalent to open surgery for moderate diverticulitis, but its role in severe disease is still being elucidated. The aim of this study was to compare short-term outcomes in patients who underwent laparoscopic sigmoidectomy for moderate and severe diverticulitis.

Methods

All patients who had elective laparoscopic sigmoidectomy for diverticulitis between April 2003 and September 2011 at the University Hospital of Luxembourg were selected from a retrospective database. The patients were divided in two groups: moderate acute diverticulitis (MAD) included patients with an episode of left-lower-quadrant pain, elevated inflammatory markers, and radiologic evidence of diverticulitis, and severe acute diverticulitis (SAD) included patients with diverticula associated with abscess, phlegmon, perforation, fistula, obstruction, bleeding, or stricture.

Results

A total of 121 patients (81 MAD and 40 SAD) underwent elective laparoscopic sigmoidectomy with primary anastomosis. There were no significant differences between the two groups with respect to demographic characteristics, except for sex ratio. In this series the overall morbidity rate at 30 postoperative days (POD) was 12.4 %, with no significant differences between MAD and SAD (16.0 vs. 5 %, respectively; P = 0.083). No significant differences were found with respect to mean length of hospital stay (6.7 vs. 7.7 days; P = 0.399) as well. The overall conversion rate to open surgery was 2.5 % (3 patients), with no difference between the two groups. Conversion to laparotomy was associated with an increased morbidity rate (11.0 % for full laparoscopy vs. 66.6 % for conversion; P = 0.040) and a longer length of stay (6.8 vs. 16.7 days; P = 0.008). There were no deaths within 30 POD.

Conclusions

Elective laparoscopic sigmoidectomy is safe and feasible for patients with moderate and severe acute diverticulitis and the outcomes are equivalent.     

Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial

Background  

Elective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results.     

Management of right-sided diverticulitis: A retrospective review from a hospital in Japan

Purpose  

Right-sided diverticulitis is a rare clinical entity in Western countries; however, in some Asian countries diverticulitis affects the right side of the colon more often than the left side. This study aims to establish some guidelines for patients with right-sided diverticulitis because at present, there are only guidelines for those with acute left-sided diverticulitis.     

Clinical characteristics of 12 cases of appendiceal diverticulitis: a comparison with 378 cases of acute appendicitis

Purpose  

Previous authors have suggested that a diverticulum of the vermiform appendix has a higher risk of perforation than acute appendicitis. Therefore, this study compared appendiceal diverticulitis with acute appendicitis to explain the characteristics of appendiceal diverticulitis.     

Robotic-assisted laparoscopic surgery for recurrent diverticulitis: experience in consecutive cases and a review of the literature

Background  

Robotic-assisted laparoscopic surgery has recently gained enthusiasm for application in colorectal surgery. We present the safety and feasibility of using the da Vinci^? robotic system for the surgical treatment of sigmoid diverticulitis.     

Laparoscopic one-stage resection of right and left colon complicated diverticulitis equivalent to hinchey stage I–II

Purpose  

The safety and effectiveness of laparoscopic surgery is well established for recurrent, uncomplicated diverticular disease, but not for complicated diverticular disease. Using the Hinchey classification, we compared laparoscopic colon resection (LAPH) with conventional open colon resection (OPH) for the treatment of complicated diverticulitis equivalent to Hinchey stage I–II.     

Laparoscopic Sigmoidectomy for Diverticulitis: a Prospective Study

Background:

Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis.

Method:

All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications.

Results:

During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%).

Conclusions:

Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.     

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann’s procedure

Background

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann’s procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

Methods

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P?Results A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1?%) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182?±?54.7?min, and EBL was 210?±?170.5?ml. Six LHP (14.6?%) were converted to open Hartmann’s for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1?%, respectively. For LLD, the operating time was 99.7?±?39.8?min, and blood loss was 34.4?±?21.2?ml. Three patients (6.4?%) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3?±?10.1 vs. 6.7?±?2.2?days, P?Conclusions Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.     

Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials

Purpose

The surgical interventions of diverticulitis vary according to its grade and severity. There is a controversy about the best of these different surgical procedures. We aimed to systematically review and meta-analyze randomized controlled trials (RCTs) comparing outcomes and complications between different surgical approaches for acute diverticulitis and its complications.

Predictive risk factors for intra- and postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis: a multivariate analysis

Background  

Laparoscopic sigmoid resection is a feasible and frequent operation for patients who suffer from recurrent diverticulitis. There is still an ongoing debate about the optimal timing for surgery in patients who suffer from recurrent diverticulitis episodes. In elective situations the complication rate for this procedure is moderate, but there are patients at high risk for perioperative complications. The few identified risk factors so far refer to open surgery. Data for the elective laparoscopic approach is rare. The objective of this study was to identify potential predictive risk factors for intra- and postoperative complications in patients who underwent laparoscopic sigmoid resection due to diverticular disease.     

Acute diverticulitis in immunosuppressed patients: a 12-year management experience

Background

Diverticular disease of the colon occurs commonly in developed countries. Immunosuppressed patients are thought to be more at risk of developing acute diverticulitis, worse disease, and higher complications secondary to therapy. This study aimed to assess outcomes for immunosuppressed patients with acute diverticulitis.

Method

A retrospective single-centre review was conducted of all patients presenting with acute diverticulitis at a major tertiary Australian hospital from 2006 to 2018.

Result

A total of 751 patients, comprising of 46 immunosuppressed patients, were included. Immunosuppressed patients were found to be older (62.25 versus 55.96, p = 0.016), have more comorbidities (median Charlson Index 3 versus 1, P < 0.001), and undergo more operative management (13.3% versus 5.1%, P = 0.020). Immunosuppressed patients with paracolic/pelvic abscesses (Modified Hinchey 1b/2) were more likely to undergo surgery (56% versus 24%, P = 0.046), while in patients with uncomplicated diverticulitis, there was no difference in immunosuppressed patients undergoing surgery (6.1% versus 5.1% P = 0.815). Immunosuppressed patients were more likely to have Grade III-IV Clavien-Dindo complication (P < 0.001).

Conclusion

Immunosuppressed patients with uncomplicated diverticulitis can be treated safely with non-operative management. Immunosuppressed patients were more likely to have operative management for Hinchey 1b/II and more likely to have grade III/IV complications.     

Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy

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.     

Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis

Purpose  

This study was designed to compare the long-term outcome of patients treated with conservative versus surgical treatment for acute sigmoid diverticulitis (SD).     

Sigmoid Diverticulitis in Young Patients—A More Aggressive Disease than in Older Patients?

Introduction  

There is controversy over whether sigmoid diverticulitis (SD) is more aggressive with a higher risk of perforation in younger than in older patients. The aim of this study was to assess the clinical presentation and outcome of patients ≤40 and >40 years old with acute diverticulitis.     

Treating acute diverticulitis in pre- and post-solid-organ transplant patients: a single-institution cohort study

Aim

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30-day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre- and post-transplant patients.

Method

This is a retrospective cohort study at a single-institution tertiary referral centre. Patients with a history of acute diverticulitis were extracted from a database of 6152 recipients of solid-organ abdominal transplant between 2000 and 2015 and stratified by the index episode of diverticulitis: before or after solid-organ transplant surgery. Outcomes included 30-day postoperative complications and failure of nonoperative management.

Results

Acute diverticulitis occurred in 93 patients, 69 (74%) posttransplant. Postcolectomy complications were higher posttransplant than pretransplant (43% vs. 13%, p = 0.04). Posttransplant status was not an independent risk factor for complications (odds ratio 3.59, 95% CI 0.79–16.31) when adjusting for sex and surgical acuity. Immediate urgent colectomy (29% vs. 31%, p = 0.84) and failure of nonoperative management (7% vs. 9%, p = 0.82) were similar. Complications occurred equally in those requiring urgent colectomy after nonoperative management and those undergoing immediate urgent colectomy.

Conclusion

Urgent colectomy rates are similar in solid-organ abdominal transplant recipients pre- and posttransplant. Posttransplant complication rates appear to be increased but transplant status as an independent factor is not significantly associated with an increased risk in this study cohort. These findings should be considered when counselling patients on the relative risks and benefits of surgical intervention for diverticulitis before versus after solid-organ transplantation.