Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?
ABSTRACT Our understanding of complicated diverticulitis is based on outdated literature. Antecedent episodes of diverticulitis are felt to increase the risk of developing complicated diverticulitis, as well as its subsequent morbidity and mortality. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce this morbidity and mortality.
A total of 150 patients with prior episodes of diverticulitis who were hospitalized with complicated diverticulitis were retrospectively analyzed. Statistical analysis was conducted using chi and Fisher exact test tests.
Patients were separated into 2 groups for analysis: group A = those with 1 or 2 prior diverticulitis episodes (n = 118) versus group B = patients with more than 2 prior episodes (n = 32). Characteristics of the groups were similar for age and preexistent comorbid conditions. The majority of patients presented with pericolonic abscess and inflammatory phlegmon. Perforated diverticulitis occurred more often in group A compared with patients with >2 episodes of diverticulitis. Because of the higher rate of perforation, patients in group A underwent surgical diversion more often than group B patients. No significant differences in operative complications, morbidity, or mortality rates were identified between the groups.
Patients with multiple (>2) episodes of diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis. Morbidity and mortality rates are not significantly different between patients with multiple episodes of diverticulitis compared with those with 1 or 2 prior attacks. Reevaluation of the practice of elective resection as a strategy for reducing the mortality and morbidity from complicated diverticulitis is needed.
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ABSTRACT: The ideal treatment of perforated diverticulitis and the indications for elective colon resection remain controversial. Considering the significant morbidity and mortality rates related to traditional resection, efforts have been made to reduce the invasiveness of surgery in recent decades. Laparoscopic peritoneal lavage has emerged as an effective alternative option. We retrospectively investigated the effectiveness of laparoscopic peritoneal lavage for perforated diverticulitis and the possibility that it could be a definitive treatment. We included patients treated with laparoscopic peritoneal lavage for perforated diverticulitis. The inclusion criteria were all emergency patients with generalized peritonitis due to Hinchey III perforated diverticulitis and some cases of Hinchey II and IV. Sixty-three patients were treated with laparoscopic peritoneal lavage. Six patients (9.5 %) had Hinchey II diverticulitis; 54 patients (85.7 %) had Hinchey III; and three patients (4.8 %) had Hinchey IV. The mean operative time was 87.3 min (±25.4 min), and the overall morbidity rate was 14.3 %. One patient died because of pulmonary embolism, and there were six early reinterventions because of treatment failure. Delayed colon resection was performed in four of the remaining 57 patients (7 %) because of recurrent diverticulitis. In the other 53 patients (93 %), we saw no recurrence of diverticulitis and no intervention was performed after a median follow-up period of 54 months (interquartile range 27-98 months). Laparoscopic peritoneal lavage for perforated diverticulitis can be considered a safe and effective alternative to traditional surgical resection, and using this approach, most elective colon resection might be avoided.Techniques in Coloproctology 12/2014; 19(2). DOI:10.1007/s10151-014-1258-1 · 1.34 Impact Factor
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ABSTRACT: Currently, the indications for elective surgery for patients who have recovered from an acute diverticulitis (AD) are controversial. We examined the natural history of AD in New York and identified risk factors for recurrent admissions and poor outcome to create a simple model to produce risk stratification groups. Poor outcome was defined as complicated disease, emergency surgery, or mortality during any recurrent admission. Data on adult diverticulitis admissions between 1985 and 2006 were extracted from the state discharge database; recurrences were monitored using unique identifiers. Survivors of nonoperative management who did not undergo subsequent elective surgery were considered eligible for recurrence. Clinical variables from the first admission with significant association with poor outcomes or recurrence were identified using multivariable analysis and were used to create risk stratification groups. A total of 237,879 individuals were identified. Of the 181,115 patients eligible for recurrence after one admission, 8.7% recurred; of the patients eligible for recurrence after two admissions, 23.2% recurred. Complicated AD or abscess and age less than 50 years allowed the creation of discrete risk groups for both recurrence and poor outcome. The majority of patients (91.3%) had no further admissions for AD. However, patients admitted for recurrence were increasingly likely to require subsequent admissions. Patients with complicated AD at the first admission, specifically abscess, had a high risk of recurrence and poor outcome and should be offered surgery. Younger patients also had higher recurrence and poor outcomes. We provide a risk stratification model to help identify patients at high risk for recurrence and poor outcome. Therapeutic study, level IV; epidemiologic/prognostic study, level III.Journal of Trauma and Acute Care Surgery 01/2015; 78(1):112-9. DOI:10.1097/TA.0000000000000466 · 1.97 Impact Factor
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ABSTRACT: Recurrence of acute diverticulitis is common, and-especially complicated recurrence-causes significant morbidity. To prevent recurrence, selected patients have been offered prophylactic sigmoid resection. However, as there is no tool to predict whose diverticulitis will recur and, in particular, who will have complicated recurrence, the indications for sigmoid resections have been variable. The objective of this study was to identify risk factors predicting recurrence of acute diverticulitis.This is a retrospective cohort study of patients presenting with computed tomography-confirmed acute diverticulitis and treated nonresectionally during 2006 to 2010. Risk factors for recurrence were identified using uni- and multivariate Cox regression.A total of 512 patients were included. History of diverticulitis was an independent risk factor predicting uncomplicated recurrence of diverticulitis (1-2 earlier diverticulitis HR 1.6, 3 or more-HR 3.2). History of diverticulitis (HR 3.3), abscess (HR 6.2), and corticosteroid medication (HR 16.1) were independent risk factors for complicated recurrence. Based on regression coefficients, risk scoring was created: 1 point for history of diverticulitis, 2 points for abscess, and 3 points for corticosteroid medication. The risk score was unable to predict uncomplicated recurrence (AUC 0.48), but was able to predict complicated recurrence (AUC 0.80). Patients were further divided into low-risk (0-2 points) and high-risk (>2 points) groups. Low-risk and high-risk groups had 3% and 43% 5-year complicated recurrence rates, respectively.Risk for complicated recurrence of acute diverticulitis can be assessed using risk scoring. The risk for uncomplicated recurrence increases along with increasing number of previous diverticulitis.