Background
The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially ...reducing the burden of one of the most common gastrointestinal diseases in the Western world.
Purpose
Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.
Methods
PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.
Results
A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6–9%,
I
2
48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (
p
= 0.619 and
p
= 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.
Conclusion
Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.
Purpose
The aim of this systematic review is to identify risk factors that can predict complicated diverticulitis. Uncomplicated diverticulitis is a self-limiting and mild disease, but 10% of ...patients with diverticulitis develop complications requiring further treatment. It is important to estimate the risk of developing complicated diverticulitis at an early stage to set the right treatment at initial presentation.
Methods
Embase, MEDLINE, and Cochrane databases were searched for studies reporting on risk factors for complicated diverticulitis. Complicated diverticulitis was defined as Hinchey ≥Ib or severe diverticulitis according to the Ambrosetti criteria. Meta-analyses were performed when at least four studies reported on the outcome of interest. This study was conducted according to the PRISMA guidelines.
Results
A total of 12 studies were included with a total of 4619 patients. Most were of reasonable quality. Only the risk factors “age” and “sex” were eligible for meta-analysis, but none showed a significant effect on the risk for complicated diverticulitis. There was reasonable quality of evidence suggesting that high C-reactive protein; white blood cell count; clinical signs including generalized abdominal pain, constipation and vomiting; steroid usage; a primary episode; and comorbidity are risk factors for complicated diverticulitis.
Conclusion
Although high-level evidence is lacking, this study identified several risk factors associated with complicated diverticulitis. Individually, these risk factors have little value in predicting the course of diverticulitis. The authors propose a prognostic model combining these risk factors which might be the next step to aid the physician in predicting the course of diverticulitis and setting the right treatment at initial presentation.
Background
Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but ...most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis.
Methods
PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls.
Results
Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent.
Conclusion
Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.
This systematic review demonstrates that the prevalence of colorectal cancer in all patients with diverticulitis is slightly higher than in controls, whereas patients with uncomplicated diverticulitis have a colorectal cancer prevalence comparable to that of asymptomatic controls from the literature. Therefore, routine colonoscopy should be omitted in those with uncomplicated diverticulitis and these patients may be referred back to the colorectal cancer screening programme. However, routine colonoscopy should remain the protocol for differential diagnosis after non‐surgical treatment of complicated diverticulitis.
Not needed routinely
Probiotics are live microorganisms which, when administered in adequate amounts, confer a health benefit on the host. Therefore, probiotic strains should be able to survive passage through the human ...gastrointestinal tract. Human gastrointestinal tract survival of probiotics in a low-fat spread matrix has, however, never been tested. The objective of this randomized, double-blind, placebo-controlled human intervention study was to test the human gastrointestinal tract survival of Lactobacillus reuteri DSM 17938 and Lactobacillus rhamnosus GG after daily consumption of a low-fat probiotic spread by using traditional culturing, as well as molecular methods. Forty-two healthy human volunteers were randomly assigned to one of three treatment groups provided with 20 g of placebo spread (n = 13), 20 g of spread with a target dose of 1 x 10⁹ CFU of L. reuteri DSM 17938 (n = 13), or 20 g of spread with a target dose of 5 x 10⁹ CFU of L. rhamnosus GG (n = 16) daily for 3 weeks. Fecal samples were obtained before and after the intervention period. A significant increase, compared to the baseline, in the recovery of viable probiotic lactobacilli in fecal samples was demonstrated after 3 weeks of daily consumption of the spread containing either L. reuteri DSM 17938 or L. rhamnosus GG by selective enumeration. In the placebo group, no increase was detected. The results of selective enumeration were supported by quantitative PCR, detecting a significant increase in DNA resulting from the probiotics after intervention. Overall, our results indicate for the first time that low-fat spread is a suitable carrier for these probiotic strains.
Background
Treatment strategies for diverticulitis with abscess formation have shifted from (emergency) surgical treatment to non‐surgical management (antibiotics with or without percutaneous ...drainage (PCD)). The aim was to assess outcomes of non‐surgical treatment and to identify risk factors for adverse outcomes.
Methods
Patients with a first episode of CT‐diagnosed diverticular abscess (modified Hinchey Ib or II) between January 2008 and January 2015 were included retrospectively, if initially treated non‐surgically. Baseline characteristics, short‐term (within 30 days) and long‐term treatment outcomes were recorded. Treatment failure was a composite outcome of complications (perforation, colonic obstruction and fistula formation), readmissions, persistent diverticulitis, emergency surgery, death, or need for PCD in the no‐PCD group. Regression analyses were used to analyse risk factors for treatment failure, recurrences and surgery.
Results
Overall, 447 patients from ten hospitals were included (Hinchey Ib 215; Hinchey II 232), with a median follow‐up of 72 (i.q.r. 55–93) months. Most patients were treated without PCD (332 of 447, 74·3 per cent). Univariable analyses, stratified by Hinchey grade, showed no differences between no PCD and PCD in short‐term treatment failure (Hinchey I: 22·3 versus 33 per cent, P = 0·359; Hinchey II: 25·9 versus 36 per cent, P = 0·149) or emergency surgery (Hinchey I: 5·1 versus 6 per cent, P = 0·693; Hinchey II: 10·4 versus 15 per cent, P = 0·117), but significantly more complications were found in patients with Hinchey II disease undergoing PCD (12 versus 3·7 per cent; P = 0·032). Multivariable analyses showed that treatment strategy (PCD versus no PCD) was not independently associated with short‐term treatment failure (odds ratio (OR) 1·47, 95 per cent c.i. 0·81 to 2·68), emergency surgery (OR 1·29, 0·56 to 2·99) or long‐term surgery (hazard ratio 1·08, 95 per cent c.i. 0·69 to 1·69). Abscesses of at least 3 cm in diameter were associated with short‐term treatment failure (OR 2·05, 1·09 to 3·86), and abscesses of 5 cm or larger with the need for surgery during short‐term follow‐up (OR 2·96, 1·03 to 8·13).
Conclusion
The choice between PCD with antibiotics or antibiotics alone as initial non‐surgical treatment of Hinchey Ib and II diverticulitis does not seem to influence outcomes.
This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short‐term treatment failure and emergency surgery respectively. Initial non‐surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short‐ and long‐term outcomes.
Most do not need drainage
Purpose
Conservative treatment strategy without antibiotics in patients with uncomplicated diverticulitis (UD) has proven to be safe. The aim of the current study is to assess the clinical course of ...UD patients who were initially treated without antibiotics and to identify risk factors for treatment failure.
Methods
A retrospective cohort study was performed including all patients with a CT-proven episode of UD (defined as modified Hinchey 1A). Only non-immunocompromised patients who presented without signs of sepsis were included. Patients that received antibiotics within 24 h after or 2 weeks prior to presentation were excluded from analysis. Patient characteristics, clinical signs, and laboratory parameters were collected. Treatment failure was defined as (re)admittance, mortality, complications (perforation, abscess, colonic obstruction, urinary tract infection, pneumonia) or need for antibiotics, operative intervention, or percutaneous abscess drainage within 30 days after initial presentation. Multivariable logistic regression analyses were used to quantify which variables are independently related to treatment failure.
Results
Between January 2005 and January 2017, 751 patients presented at the emergency department with a CT-proven UD. Of these, 186 (25%) patients were excluded from analysis because of antibiotic treatment. A total of 565 patients with UD were included. Forty-six (8%) patients experienced treatment failure. In the multivariable analysis, a high CRP level (> 170 mg/L) was a significant predictive factor for treatment failure.
Conclusion
UD patients with a CRP level > 170 mg/L are at higher risk for non-antibiotic treatment failure. Clinical physicians should take this finding in consideration when selecting patients for non-antibiotic treatment.
Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear recommendations on whether or not ...to operate, even though recent studies suggest an improved quality of life following surgery. The aim of this study is therefore to compare quality of life in patients with recurrent or ongoing diverticulitis treated conservatively versus surgically, giving a more definitive answer to the question of whether or not to operate on these patients.
A systematic literature search was conducted in EMBASE, MEDLINE and Cochrane. Only comparative studies reporting on quality of life were included. Statistical analysis included calculation of weighted mean differences and pooled odds ratios.
Five studies were included; two RCT's and three retrospective observational studies. Compared to conservative treatment, the SF-36 scores were higher in the surgically treated group at each follow-up moment but only the difference in SF-36 physical scores at six months follow-up was statistically significant (MD 6.02, 95%CI 2.62-9.42). GIQLI scores were also higher in the surgical group with a MD of 14.01 (95%CI 8.15-19.87) at six months follow-up and 7.42 (95%CI 1.23-12.85) at last available follow-up. Also, at last available follow-up, significantly fewer recurrences occurred in the surgery group (OR 0.10, 95%CI 0.05-0.23,
< 0.001).
Although surgery for recurrent diverticulitis is not without risk, it might improve long-term quality of life in patients suffering from recurrent- or ongoing diverticulitis when compared to conservative treatment. Therefore, it should be considered in this patient group.
Aim Validated guidelines for the surgical and non‐surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the ...evaluation, follow‐up and treatment of patients with an internal or external RP.
Method A 36‐question questionnaire in English about the evaluation, treatment and follow‐up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e‐mail.
Results In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow‐up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients.
Conclusion The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.
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