Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study.

BACKGROUND: Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. METHODS: This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. RESULTS: Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). CONCLUSION: Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.

Diverticulitis is inflammation in pouches of the large bowel. Rarely, diverticulitis can lead to a bowel perforation causing peritonitis. Traditionally, it was treated by resection of the inflamed bowel with a stoma. A milder treatment has been proposed in which the abdomen is rinsed with saline laparoscopically and drained (laparoscopic lavage). This study aimed to examine the outcomes of laparoscopic lavage in Sweden. Our findings support the use of this method in younger and healthier patients with a history of no or only minor previous abdominal surgery.

Recurrence of severe diverticulitis is associated with age and birth decade.

BACKGROUND: The risk of recurrence is an important consideration when deciding to treat patients medically or with elective colectomy after recovery from diverticulitis. It is unclear whether age is associated with recurrence. This study aimed to examine the relationship between age and the risk of recurrent diverticulitis while considering important epidemiologic factors, such as birth decade. METHODS: The Utah Population Database was used to identify individuals with incident severe diverticulitis, defined as requiring an emergency department visit or hospitalization, between 1998 and 2018. This study measured the relationship between age and recurrent severe diverticulitis after adjusting for birth decade and other important variables, such as sex, urban/rural status, complicated diverticulitis, and body mass index using a Cox proportional hazards model. RESULTS: The cohort included 8606 individuals with a median age of 61 years at index diverticulitis diagnosis. After adjustment, among individuals born in the same birth decade, increasing age at diverticulitis onset was associated with an increased risk of recurrent diverticulitis (hazard ratio [HR] for 10 years, 1.8; 95% CI, 1.5-2.1). Among individuals with the same age of onset, those born in a more recent birth decade were also at greater risk of recurrent diverticulitis (HR, 1.9; 95% CI, 1.6-2.3). CONCLUSION: Among individuals with an index episode of severe diverticulitis, recurrence was associated with increasing age and more recent birth decade. Clinicians may wish to employ age-specific strategies when counseling patients regarding treatment options after a diverticulitis diagnosis.

Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals.

BACKGROUND: The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis. METHOD: The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results. RESULTS: Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks. CONCLUSION: The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis.

BACKGROUND: Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS: This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS: Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION: Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.

Right-sided colonic diverticulitis. Short and long-term surgical outcomes and 2-year quality of life.

AIM: We aimed to investigate the short and the long-term outcomes and 2-year Quality of Life (QoL) of patients with right-sided colonic diverticulitis (RCD) surgically managed. METHOD: We conducted an ambidirectional cohort study of patients with RCD undergoing surgery between 2012/2022. A colonoscopy was performed at 1-year post surgery. The enrolled patients completed the EuroQoL (EQ-5D-3L) during a regular follow-up visit at 12 and 24 months after surgery. RESULTS: Three hundred nineteen patients with RCD were selected: 223 (70%) patients were treated by non-operative management (NOM) while 33 underwent surgery. Acute diverticulitis occurred in 30 patients: 9 (27.2%) were classified by CT as uncomplicated and 21 (63.6%) as complicated diverticulitis. Additionally, chronic diverticulitis occurred in 3 cases (9.2%). Specifically, 27 patients were classified by CT as 1a (81.8%) and 6 patients as 3 (18.2%). Right hemicolectomy was performed in 30 patients (90.8%), and ileo-caecectomy in 3 (9.2%). Nine (27.27%) experienced postoperative complications: 7 (77.7%) were classified according to the Clavien-Dindo as grade I-II, and 2 (22.2%) as grade III. No disease recurrence or colorectal cancer (CRC) was detected on colonoscopy. Thirty (90.8%) patients completed the 24-month follow-up. A statistically significant difference between preoperative and 24-month QoL index values (median 0.72; IQR = 0.57-0.8 vs. median 0.9; IQR = 0.82-1; p = 0.0003) was observed. CONCLUSIONS: The study results demonstrate satisfactory surgical outcomes and a better QoL after surgery. No disease recurrence or CRC was observed at colonoscopy 1 year after surgery.

Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

The Patient Perspective on Colectomy for Recurrent Diverticulitis: A Qualitative Study.

OBJECTIVE: Understand the patient's decision-making process regarding colectomy for recurrent diverticulitis. BACKGROUND: The decision to pursue elective colectomy for recurrent diverticulitis is highly preference-sensitive. Little is known about the patient's perspective in this decision-making process. METHODS: We performed a qualitative study utilizing focus groups of patients with recurrent diverticulitis at 3 centers across the United States. Using an iterative inductive/deductive approach, we developed a conceptual framework to capture the major themes identified in the coded data. RESULTS: From March 2019 to July 2020, 39 patients were enrolled across 3 sites and participated in 6 focus groups. After coding the transcripts using a hierarchical coding system, a conceptual framework was developed. Major themes identified included participants' beliefs about surgery, such as normative beliefs (eg, subjective, value placed on surgery), control beliefs (eg, self-efficacy, stage of change), and anticipated outcomes (eg, expectations, anticipated regret); the role of behavioral management strategies (eg, fiber, eliminate bad habits); emotional experiences (eg, depression, embarrassment); current symptoms (eg, severity, timing); and quality of life (eg, cognitive load, psychosocial factors). Three sets of moderating factors influencing patient choice were identified: clinical history (eg, source of diagnosis, multiple surgeries), clinical protocols (eg, pre-op and post-op education), and provider-specific factors (eg, specialty, choice of surgeon). CONCLUSIONS: Patients view the decision to undergo colectomy through 3 major themes: their beliefs about surgery, their psychosocial context, and moderating factors that influence participant choice to undergo surgery. This knowledge is essential both for clinicians counseling patients who are considering colectomy and for researchers studying the process to optimize care for recurrent diverticulitis.

Predictive risk model of recurrence of acute diverticulitis after the first episode.

INTRODUCTION: The recurrence of acute diverticulitis (AD) of the colon is frequent and leads to hospital readmissions and the need for elective surgery in selected cases. It is important to individualize risk factors and develop predictive tools for their identification. MATERIALS AND METHODS: This prospective observational study included 368 patients who were diagnosed with AD between 2016 and 2021 in a tertiary general university hospital during their first episode and who had a good response to antibiotic, percutaneous, or peritoneal lavage treatment. Univariate and multivariate Cox regression analyses of the variables associated with recurrence were performed. Subsequently, a predictive risk score was developed and validated through survival studies. RESULTS: After a median follow-up of 50 months, there were 71 (19.3%) cases of recurrence out of a total of 368 patients. The mean time of recurrence was 15 months, and 73.3% of cases of recurrence occurred before 2 years of follow-up. Recurrence was independently associated with presentation with colonic perforation in the antimesenteric location (HR 3.67 95% CI [1.59-8.4]) and a CRP level greater than 100 mg/dl (HR 1.69 95% CI [1.04-2.77). A score with 5 variables was created that differentiated two risk groups: intermediate risk (0-3 points), with 19% recurrence and high risk (more than 3 points), with 42% recurrence. CONCLUSIONS: The risk of recurrence after the first episode of diverticulitis can be estimated using predictive scores. The detection of high-risk patients facilitates the individualization of follow-up and treatment.

Free perforation during the first episode of acute diverticulitis: can it be avoided?

The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016-1.067), lung disease (OR 2.154 95% CI 1.038-4.472) and immunosuppression (OR: 2.812 95% CI 1.315-6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes.

Transverse colon diverticulitis mimicking acute appendicitis.

Diverticulitis in a solitary transverse colon diverticulum is uncommon, with only a handful of cases documented in the literature. There are various clinical manifestations of the disease, which make clinical and radiological diagnosis rather challenging. Herein, we present a case of a premenopausal female patient in her late 40s who presented to the emergency department, complaining of right lower quadrant abdominal pain, nausea, anorexia and fever. Following clinical, biochemical and radiological tests, the patient was prepared for surgical operation, with the presumed diagnosis of acute appendicitis. An appendicectomy was planned via a McBurney incision. Notably, no inflammation of the appendix was discovered. However, on further exploration, an inflammatory mass was identified in the transverse colon, which was subsequently excised and sent for histological examination. The histology results confirmed the presence of a ruptured solitary transverse colon diverticulum, accompanied by an adjacent mesenteric abscess. The patient's postoperative recovery was uneventful.

Sarcopenia is a Poor Predictor of Outcomes in Elective Colectomy for Diverticulitis.

BACKGROUND: Sarcopenia is associated with adverse perioperative outcomes in patients undergoing operations for malignancy, but its influence on patients undergoing elective colectomy for diverticulitis is unknown. We hypothesized that sarcopenia is associated with adverse perioperative events in patients undergoing elective colectomy for diverticulitis. METHODS: Comorbidities, operative characteristics, and postoperative complications were extrapolated from our institutional EMR in patients undergoing elective colectomy for diverticulitis from 2016 to 2020. Sarcopenia was calculated using perioperative imaging and defined by standard skeletal muscle index (SMI) and psoas muscle index (PMI) thresholds. Univariate analysis was used to compare sarcopenic and non-sarcopenic patients. RESULTS: 148 patients met inclusion criteria. Using SMI thresholds, 95 patients (64%) were sarcopenic. With SMI criteria, sarcopenic patients were older (67 vs 52 years old; P < .01) and had lower BMIs (26.2 vs 34.0, respectively; P < .001) than non-sarcopenic patients. There were no differences in baseline characteristics, postoperative complications, and non-home discharge between groups (P > .05 for all). Postoperative length of stay was greater in sarcopenic patients (3 IQR 2-5 vs 2 IQR 2-3 days; P < .01). Using PMI thresholds, 68 (46%) met criteria for sarcopenia. Using PMI thresholds, sarcopenic patients were older (68 vs 57.5 years old; P < .01) and had lower BMIs (25.8 vs 32.8; P < .01). There were no differences in comorbidities or measured operative outcomes between groups (P > .05 for all), other than postoperative length of stay which was longer in the sarcopenic group (3.5 IQR 3-5 vs 2 IQR 2-3; P < .01). CONCLUSIONS: Incidence of sarcopenia was high in patients undergoing elective colectomy for diverticulitis in our practice, but sarcopenia was not associated with adverse perioperative outcomes. In select patients, elective colectomy for diverticulitis can be safely performed in the presence of sarcopenia.

Treating a Bypass with Bypass Surgery: Repair of a Duodeno-sigmoid Fistula Complicating Acute Diverticulitis.

Diverticular disease is common in Western countries; one-third of patients with diverticular disease develop diverticulitis during their lifetime of whom 5% may experience serious complications. We describe a rare complication of diverticulitis: a duodeno-colic fistula in a patient with an elongated sigmoid colon (dolicosigma). The patient complained of abdominal pain, diarrhea, weight loss, and feculent vomiting. Radiological studies and gastroscopy demonstrated a fistula between the second portion of the duodenum and the sigmoid colon. Curative surgery cured the fistula and completely resolved its associated signs and symptoms.

What are the differences between the three most used classifications for acute colonic diverticulitis? A comparative multicenter study.

BACKGROUND: Acute left-sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. Currently, the most popular classifications, based on radiological findings, are the modified Hinchey, American Association for the Surgery of Trauma (AAST), and World Society of Emergency Surgery (WSES) classifications. We hypothesize that all classifications are equivalent in predicting outcomes. METHODS: This is a retrospective study of 597 patients from four medical centers between 2014 and 2021. Based on clinical, radiological, and intraoperative findings, patients were graded according to the three classifications. Regression analysis and receiver operating characteristic curve analysis were used to compare six outcomes: need for intervention, complications, major complications (Clavien-Dindo >2), reintervention, hospital length of stay, and mortality. RESULTS: A total of 597 patients were included. Need for intervention, morbidity, and reintervention rates significantly increased with increasing AAST, modified Hinchey, and WSES grades. The area under the curve (AUC) for the need for intervention was 0.84 for AAST and 0.81 for modified Hinchey ( p = 0.039). The AUC for major complications was 0.75 for modified Hinchey and 0.70 for WSES ( p = 0.009). No differences were found between the three classifications when comparing AUCs for mortality, complications, and reintervention rates. CONCLUSION: The AAST, WSES, and modified Hinchey classifications are similar in predicting complications, reintervention, and mortality rates. American Association for the Surgery of Trauma and modified Hinchey scores result the most adequate for predicting the need for surgery and the occurrence of major complications. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula.

BACKGROUND: Current guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management. METHODS: A retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded. RESULTS: Seventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1-63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities. CONCLUSION: The challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study.

OBJECTIVE: To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19. METHODS: From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21). RESULTS: A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity. CONCLUSION: This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018.

BACKGROUND: Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years. METHODS: Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression. RESULTS: Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP. CONCLUSIONS: Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.

Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients.

OBJECTIVE: Weighing the perioperative risk of elective sigmoidectomy is done regardless of the specific diverticulitis classification. The aim of this study is to evaluate surgical outcomes according to the classification grade and the indication. METHODS: All patients who underwent elective colonic resection for diverticulitis during the ten-year study period were included. They were divided into two groups: relative surgery indication (RSI) and absolute surgery indication (ASI). RSI included microabscess and recurrent uncomplicated disease. ASI included macroabscess and recurrent complicated disease. Propensity score-matching (PSM, 1:1) was performed. RESULTS: 585 patients fulfilled criteria for RSI and 318 patients fulfilled criteria for ASI. In the univariate analysis, RSI patients were younger (62 vs. 67.7 years, p < 0.001), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p < 0.001), were less immunosuppressed (3.4% vs. 6.9%, p = 0.021) and suffered less often from coronary heart disease (3.8% vs. 7.2%, p = 0.025). After PSM, 318 RSI vs. 318 ASI patients were selected; baseline characteristics results were comparable. The proportion of planned laparoscopic resection was 93% in RSI versus 75% in ASI (p < 0.001), and the conversion rate to open surgery for laparoscopic resection was 5.0% and 13.8% in RSI versus ASI, respectively (p < 0.001). Major morbidity (Clavien/Dindo ≥ IIIb) occurred less frequently in RSI (3.77% vs. 10%, p = 0.003). A defunctioning stoma was formed in 0.9% and 11.0% in RSI vs ASI, respectively (p < 0.001). CONCLUSION: The lower risk for postoperative morbidity, the higher chance for a laparoscopic resection and the decreased rate of stoma formation are attributed to patients with recurrent uncomplicated diverticulitis or diverticulitis including a microabscess as compared to patients with complicated diverticulitis or diverticulitis and a macroabscess, and this applies even after PSM.