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1
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Garfinkle R, Boutros M. Current Management of Diverticulitis. Adv Surg 2024; 58:87-106. [PMID: 39089789 DOI: 10.1016/j.yasu.2024.04.017] [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] [Indexed: 08/04/2024]
Abstract
Over the last few decades, our understanding of the pathophysiology and natural history of sigmoid diverticulitis has greatly improved. This knowledge has challenged many of the traditional principles in the management for diverticulitis, such as routine antibiotic administration in all cases, number-based recommendations for elective surgery, and the necessity for an end colostomy in emergency surgery. This review will cover the breadth of management for sigmoid diverticulitis, covering both uncomplicated and complicated disease as well as elective and emergent disease presentations. New and emerging concepts in management will be highlighted with a particular focus on level-1 data, when available.
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Affiliation(s)
- Richard Garfinkle
- Division of Mayo Clinic Colon and Rectal Surgery, 200 First Street, SW, Rochester, MN 55905, USA; Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marylise Boutros
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Department of Colorectal Surgery, Cleveland Clinic Florida, Ellen Leifer Shulman and Steven Shulman Digestive Disease Institute, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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2
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Lee JG, Park YE, Chang JY, Song HJ, Kim DH, Yang YJ, Kim BC, Lee SH, You MW, Kim SE. Diagnosis and management of acute colonic diverticulitis: results of a survey among Korean gastroenterologists. Korean J Intern Med 2023; 38:672-682. [PMID: 37586812 PMCID: PMC10493441 DOI: 10.3904/kjim.2023.133] [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: 03/19/2023] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS Some management strategies for acute colonic diverticulitis remain controversial in Korean real-world practice because their clinical features differ from those in the West. This study aimed to investigate the opinions of Korean physicians regarding the diagnosis and treatment of acute diverticulitis. METHODS A web-based survey was conducted among gastroenterologists specializing on treating lower gastrointestinal disorders. The questionnaires concerned overall management strategies for colonic diverticulitis, including diagnosis, treatment, and follow-up. RESULTS In total, 209 gastroenterologists responded to the survey. Less than one-fourth of the respondents (23.6%) answered that left-sided colonic diverticulitis is more likely to be complicated than right-sided colonic diverticulitis. Most respondents agreed that immunocompromised patients with diverticulitis have worse clinical outcomes than immunocompetent patients (71.3%). Computed tomography was the most preferred tool for diagnosing diverticulitis (93.9%). Approximately 89% of the respondents answered that they believed antibiotic treatment is necessary to treat acute uncomplicated diverticulitis. Most respondents (92.6%) agreed that emergency surgery is not required for diverticulitis with an abscess or microperforation without panperitonitis. Further, 94.7% of the respondents agreed that colon cancer screening is necessary in patients aged ≥ 50 years with diverticulitis after they have recovered from acute illness. Many respondents (71.4%) agreed that surgery for recurrent diverticulitis should be individualized. CONCLUSION Opinions regarding management strategies for colonic diverticulitis among Korean gastroenterologists were well agreed upon in some areas but did not agree well in other areas. Evidence-based guidelines that meet the practical needs of the Korean population should be developed.
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Affiliation(s)
- Jae Gon Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong,
Korea
| | - Yong Eun Park
- Division of Gastroenterology, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
| | - Ji Young Chang
- Department of Health Promotion Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Hyun Joo Song
- Division of Gastroenterology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju,
Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam,
Korea
| | - Young Joo Yang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon,
Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang,
Korea
| | - Shin Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
| | - Myung-Won You
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul,
Korea
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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]
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4
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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]
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Binda GA. Management of acute perforated diverticulitis with generalized peritonitis: is this the end of the Hartmann’s era? Tech Coloproctol 2020; 24:509-511. [PMID: 32277305 DOI: 10.1007/s10151-020-02201-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/20/2023]
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6
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Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, Dreznik Y, Zbar AP, Tulchinsky H, Avital S, Mavor E, Kashtan H, Klausner JM, Gutman M, Zmora O, Wasserberg N. Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis. J Visc Surg 2020; 157:395-400. [PMID: 31954631 DOI: 10.1016/j.jviscsurg.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. PATIENTS AND METHODS A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. RESULTS One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4). CONCLUSION Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.
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Affiliation(s)
- N Horesh
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel.
| | - Y Lessing
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - I Kent
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kammar
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; The Hebrew University-Hadassah Medical School, Jerusalem 9112001 Israel
| | - A Ben-Yaacov
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - Y Dreznik
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - A P Zbar
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Tulchinsky
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - S Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, 4428164 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - E Mavor
- Department of Surgery, Kaplan Medical Center, Rehovot, 7661041 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - H Kashtan
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - J M Klausner
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, 6423906 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - M Gutman
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - O Zmora
- Department of General Surgery B and Organ Transplantation, Sheba Medical Center, Tel Hashomer, 5262601 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
| | - N Wasserberg
- Department of Surgery B, Rabin Medical Center-Beilinson Hospital, Petach Tikva 4941492 Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801 Israel
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7
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Emile SH, Elfeki H, Sakr A, Shalaby M. Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis, and meta-regression of predictors of treatment failure. Tech Coloproctol 2018; 22:499-509. [PMID: 29980885 DOI: 10.1007/s10151-018-1817-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/27/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Diverticulitis is a common complication of diverticular disease of the colon. While complicated diverticulitis often warrants intervention, acute uncomplicated diverticulitis (AUD) is usually managed conservatively. The aim of the present review was to evaluate the efficacy and safety of conservative treatment of AUD without antibiotics compared to standard antibiotic treatment. METHODS A systematic literature review in compliance with PRISMA guidelines was conducted. Electronic databases including PubMed/Medline, Scopus, Embase and Cochrane central register of controlled trials were searched. Studies that assessed efficacy and safety of treatment of AUD without antibiotics were included. Outcome parameters were rates of treatment failure, recurrence of diverticulitis, complications and mortality, readmission to hospital, and need for surgery. RESULTS Nine studies including 2565 patients were included to the review. Of these patients, 65.1% were treated conservatively without antibiotics. Treatment failure was observed in 5.1% of patients not-given-antibiotic treatment versus 3.4% of those given antibiotic treatment. Recurrent diverticulitis occurred in 9.3% of patients in the non-antibiotic group versus 12.1% of patients in the antibiotic group. On meta-analysis of the studies, there were no significant differences between non-antibiotic and antibiotic treatment groups regarding rates of treatment failure (OR = 1.5, p = 0.06), recurrence of diverticulitis (OR = 0.81, p = 0.2), complications (OR = 0.56, p = 0.25), readmission rates (OR = 0.97, p = 0.91), need for surgery (OR = 0.59, p = 0.28), and mortality (OR = 0.64, p = 0.47). The only variable that was significantly associated with treatment failure in the non-antibiotic treatment group was associated comorbidities (standard error (SE) = - 0.07, 95% CI - 0.117 - 0.032; p < 0.001). CONCLUSIONS Treatment of AUD without antibiotics is feasible, safe, and effective. Adding broad-spectrum antibiotics to the treatment regimen did not serve to decrease treatment failure, recurrence, complications, hospital readmissions, and need for surgery significantly compared to non-antibiotic treatment.
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Affiliation(s)
- S H Emile
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura University, Elgomhuoria Street, Mansoura City, Egypt.
| | - H Elfeki
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura University, Elgomhuoria Street, Mansoura City, Egypt
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - A Sakr
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura University, Elgomhuoria Street, Mansoura City, Egypt
| | - M Shalaby
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura University, Elgomhuoria Street, Mansoura City, Egypt
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Dahl C, Crichton M, Jenkins J, Nucera R, Mahoney S, Marx W, Marshall S. Evidence for Dietary Fibre Modification in the Recovery and Prevention of Reoccurrence of Acute, Uncomplicated Diverticulitis: A Systematic Literature Review. Nutrients 2018; 10:nu10020137. [PMID: 29382074 PMCID: PMC5852713 DOI: 10.3390/nu10020137] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022] Open
Abstract
In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review the evidence and develop recommendations for dietary fibre modifications, either alone or alongside probiotics or antibiotics, versus any comparator in adults in any setting with or recently recovered from acute, uncomplicated diverticulitis. Intervention and observational studies in any language were located using four databases until March 2017. The Cochrane Risk of Bias tool and GRADE were used to evaluate the overall quality of the evidence and to develop recommendations. Eight studies were included. There was "very low" quality evidence for comparing a liberalised and restricted fibre diet for inpatient management to improve hospital length of stay, recovery, gastrointestinal symptoms and reoccurrence. There was "very low" quality of evidence for using a high dietary fibre diet as opposed to a standard or low dietary fibre diet following resolution of an acute episode, to improve reoccurrence and gastrointestinal symptoms. The results of this systematic review and GRADE assessment conditionally recommend the use of liberalised diets as opposed to dietary restrictions for adults with acute, uncomplicated diverticulitis. It also strongly recommends a high dietary fibre diet aligning with dietary guidelines, with or without dietary fibre supplementation, after the acute episode has resolved.
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Affiliation(s)
- Camilla Dahl
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Megan Crichton
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Julie Jenkins
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Romina Nucera
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Sophie Mahoney
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Wolfgang Marx
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
- School of Allied Health, La Trobe University, Melbourne, VIC 3086, Australia.
| | - Skye Marshall
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
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9
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Siddiqui J, Zahid A, Hong J, Young CJ. Colorectal surgeon consensus with diverticulitis clinical practice guidelines. World J Gastrointest Surg 2017; 9:224-232. [PMID: 29225733 PMCID: PMC5714804 DOI: 10.4240/wjgs.v9.i11.224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand.
METHODS A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios.
RESULTS The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher’s exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001).
CONCLUSION While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.
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Affiliation(s)
- Javariah Siddiqui
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
| | - Assad Zahid
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Jonathan Hong
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Christopher John Young
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
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10
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Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, Dreznik Y, Tulchinsky H, Avital S, Mavor E, Wasserberg N, Kashtan H, Klausner JM, Gutman M, Zmora O. Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study. Int J Colorectal Dis 2017; 32:1577-1582. [PMID: 28879552 DOI: 10.1007/s00384-017-2897-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making. METHODS Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers. RESULTS Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure. CONCLUSION Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.
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Affiliation(s)
- Nir Horesh
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Surgery and Transplantations B, Sheba Medical Center, 52621, Tel-Hashomer, Israel.
| | - Yonatan Lessing
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yaron Rudnicki
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Ilan Kent
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Haguy Kammar
- Department of Surgery, Kaplan Medical Center, Rehovot, Israel.,School of Medicine, Hadassah-Hebrew University, Jerusalem, Israel
| | - Almog Ben-Yaacov
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Yael Dreznik
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shmuel Avital
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Meir Medical Center, Kfar Saba, Israel
| | - Eli Mavor
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Nir Wasserberg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Hanoch Kashtan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery B, Rabin Medical Center, Petah Tikva, Israel
| | - Joseph M Klausner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Mordechai Gutman
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Zmora
- Department of General Surgery and Transplantations B, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Stam MAW, Draaisma WA, van de Wall BJM, Bolkenstein HE, Consten ECJ, Broeders IAMJ. An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study. Colorectal Dis 2017; 19:372-377. [PMID: 27611011 DOI: 10.1111/codi.13505] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/14/2016] [Indexed: 02/08/2023]
Abstract
AIM The optimal diet for uncomplicated diverticulitis is unclear. Guidelines refrain from recommendation due to lack of objective information. The aim of the study was to determine whether an unrestricted diet during a first acute episode of uncomplicated diverticulitis is safe. METHOD A prospective cohort study was performed of patients diagnosed with diverticulitis for the first time between 2012 and 2014. Requirements for inclusion were radiologically proven modified Hinchey Ia/b diverticulitis, American Society of Anesthesiologists class I-III and the ability to tolerate an unrestricted diet. Exclusion criteria were the use of antibiotics and suspicion of inflammatory bowel disease or malignancy. All included patients were advised to take an unrestricted diet. The primary outcome parameter was morbidity. Secondary outcome measures were the development of recurrence and ongoing symptoms. RESULTS There were 86 patients including 37 (43.0%) men. All patients were confirmed to have taken an unrestricted diet. There were nine adverse events in seven patients. These consisted of readmission for pain (five), recurrent diverticulitis (one) and surgery (three) for ongoing symptoms (two) and Hinchey Stage III (one). Seventeen (19.8%) patients experienced continuing symptoms 6 months after the initial episode and 4 (4.7%) experienced recurrent diverticulitis. CONCLUSION The incidence of complications among patients taking an unrestricted diet during an initial acute uncomplicated episode of diverticulitis was in line with that reported in the literature.
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Affiliation(s)
- M A W Stam
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - W A Draaisma
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - B J M van de Wall
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - H E Bolkenstein
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - I A M J Broeders
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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12
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Substantial variation among hernia experts in the decision for treatment of patients with incisional hernia: a descriptive study on agreement. Hernia 2016; 21:271-278. [DOI: 10.1007/s10029-016-1562-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/25/2016] [Indexed: 12/20/2022]
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13
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Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, Consten EC, van der Hoeven JA, Eijsbouts QA, Faneyte IF, Bemelman WA, Dijkgraaf MG, Boermeester MA. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 2016; 104:52-61. [PMID: 27686365 DOI: 10.1002/bjs.10309] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/29/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or without antibiotics for a first episode of uncomplicated acute diverticulitis. METHODS Patients with CT-proven, primary, left-sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow-up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention-to-treat and per-protocol analyses were done. RESULTS A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6-35) days for the observational and 12 (7-30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1-sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per-protocol analyses were concordant with the intention-to-treat analyses. CONCLUSION Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L Daniels
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Ç Ünlü
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Departments of Surgery, Medical Centre Alkmaar, Alkmaar, The Netherlands
| | - N de Korte
- Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - S van Dieren
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - B C Vrouenraets
- Department of Surgery, Onze Lieve Vrouwe Gasthuis West, Amsterdam, The Netherlands
| | - E C Consten
- Meander Medical Centre, Amersfoort, The Netherlands
| | | | - Q A Eijsbouts
- Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - I F Faneyte
- Ziekenhuisgroep Twente Hospital, Almelo, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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14
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Dréanic J, Sion E, Dhooge M, Dousset B, Camus M, Chaussade S, Coriat R. Traitement de la diverticulite aiguë sigmoïdienne : revue de la littérature. JOURNAL EUROPÉEN DES URGENCES ET DE RÉANIMATION 2016; 28:26-38. [DOI: 10.1016/j.jeurea.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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15
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A national evaluation of the management practices of acute diverticulitis. Surgeon 2016; 15:206-210. [PMID: 26791395 DOI: 10.1016/j.surge.2015.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/17/2015] [Accepted: 12/20/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases. METHODS A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated. RESULTS Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required. CONCLUSION This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-26. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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17
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[Treatment of the acute diverticulitis: A systematic review]. Presse Med 2015; 44:1113-25. [PMID: 26358668 DOI: 10.1016/j.lpm.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/23/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023] Open
Abstract
Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.
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Affiliation(s)
- Anthony A Meyer
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4001 Burnett-Womack Building, Chapel Hill, NC 27599-7050, USA
| | - Timothy S Sadiq
- Division of GI Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4035 Burnett-Womack, CB 7081, Chapel Hill, NC 27599-7081, USA.
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19
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Savage SA, Klekar CS, Priest EL, Crandall ML, Rodriguez BC, Shafi S. Validating a new grading scale for emergency general surgery diseases. J Surg Res 2015; 196:264-9. [PMID: 25888498 DOI: 10.1016/j.jss.2015.03.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/05/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) recently developed a grading scale for measuring anatomic severity of emergency general surgery (EGS) diseases. Grades were developed by expert consensus and have not been validated. The study purpose was to measure inter-rater reliability of the grading scale using colonic diverticulitis and to measure the association between disease grade and patient outcomes. METHODS All charts were reviewed and independently assigned AAST grades based on specific disease criteria. Inter-rater reliability was measured using a kappa coefficient. Multivariate regression models were used to determine the relationship between AAST disease grade and patient outcomes adjusted for age, comorbidities, and patient physiology. RESULTS Over 70% of patients demonstrated mild disease (grades I and II). No deaths were encountered. Inter-rater reliability for grade assignment was moderate (kappa coefficient, 0.43; 95% confidence interval, 0.31-0.56), with 67% concordance in grades. Compared to grade I, complications were similar in grade II but increased significantly with higher grades (grade III odds ratio [OR], 3.13 [1.32-7.41]; grade IV OR, 8.18 [2.09-32.0]; and grade V OR, 10.2 [2.68-38.90]). Compared to grade I, length of stay increased with higher grades (grade II incidence rate ratio [IRR], 1.30 [1.07-1.60]; grade III IRR, 2.4 [1.93-2.98]; grade IV IRR, 3.2 [2.27-4.60]; and grade V IRR, 2.6 [1.82-3.60]). CONCLUSIONS The EGS grading scale for diverticulitis demonstrated moderate inter-rater reliability. Higher grades were independently associated with complications and length of stay. The findings provide a positive validation that the EGS scale is easily used and effective.
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Affiliation(s)
- Stephanie A Savage
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
| | - Christopher S Klekar
- Institute for Health Care Research and Improvement, Baylor Scott & White Health, Dallas, Texas
| | - Elisa L Priest
- Institute for Health Care Research and Improvement, Baylor Scott & White Health, Dallas, Texas
| | - Marie L Crandall
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Briana C Rodriguez
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Shahid Shafi
- Institute for Health Care Research and Improvement, Baylor Scott & White Health, Dallas, Texas
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20
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-42. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
- Rosario Cuomo, Department of Clinical Medicine and Surgery, Federico II University Hospital School of Medicine via S. Pansini 5, 80131 Napoli, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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21
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Costa G, La Torre M, Frezza B, Fransvea P, Tomassini F, Ziparo V, Balducci G. Changes in the surgical approach to colonic emergencies during a 15-year period. Dig Surg 2014; 31:197-203. [PMID: 25170867 DOI: 10.1159/000365254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 06/15/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. MATERIALS AND METHODS A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. RESULTS Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). CONCLUSIONS Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.
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Affiliation(s)
- Gianluca Costa
- Department of General Surgery, Surgical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, Faculty of Medicine and Psychology, University of Rome 'La Sapienza', St. Andrea Hospital, Rome, Italy
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23
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Abstract
Diverticulosis and its major complications, diverticulitis and diverticular bleeding, are increasingly common indications for hospitalization and outpatient visits. Recent publications in the field of diverticular disease have challenged long-standing disease concepts and management strategies. This article will highlight studies which have helped to clarify the contribution of genetic factors, fiber consumption and medication use to the development of diverticular disease, the role of antibiotics in the treatment of acute diverticulitis, and the association between diverticulitis, irritable bowel syndrome, and colon cancer.
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Affiliation(s)
- Adam W Templeton
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA 98105, USA.
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25
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Abstract
BACKGROUND Laparoscopic lavage has shown promising results in nonfeculent perforated diverticulitis. It is an appealing strategy; it avoids the complications associated with resection. However, there has been some reluctance to widespread uptake because of the scarcity of large-scale studies. OBJECTIVE This study investigated national trends in management of perforated diverticulitis. DESIGN This retrospective population study used an Irish national database to identify patients acutely admitted with diverticulitis, as defined by the International Classification of Diseases. Demographics, procedures, comorbidities, and outcomes were obtained for the years 1995 to 2008. SETTINGS The study was conducted in Ireland. PATIENTS Patients with International Classification of Diseases codes corresponding to diverticulitis who underwent operative intervention were included. MAIN OUTCOME MEASURES The primary outcome was mortality, and secondary outcomes were length of stay and postoperative complications. RESULTS Two thousand four hundred fifty-five patients underwent surgery for diverticulitis, of whom 427 underwent laparoscopic lavage. Patients selected for laparoscopic lavage had lower mortality (4.0% vs 10.4%, p < 0.001), complications (14.1% vs 25.0%, p < 0.001), and length of stay (10 days vs 20 days, p < 0.001) than those requiring laparotomy/resection. Patients older than 65 years were more likely to die (OR 4.1, p < 0.001), as were those with connective tissue disease (OR 7.3, p < 0.05) or chronic kidney disease (OR 8.0, p < 0.001). LIMITATIONS This retrospective study is limited by the quality of data obtained and is subject to selection bias. Furthermore, the lack of disease stratification means it is not possible to identify the extent of peritonitis; feculent peritonitis has worse outcomes and is not likely to be included in the lavage group. CONCLUSIONS The number of patients selected for laparoscopic lavage in perforated diverticulitis is increasing, and the outcomes in this study are comparable to other reports. Those patients in whom laparoscopic lavage alone was suitable had lower mortality and morbidity than those in whom resection was considered necessary.
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