Challenges and Opportunities in the Elective Management of Diverticulitis: Perspectives From a National Sample of Colorectal Surgeons.

BACKGROUND: Diverticulitis is a complex, heterogeneous disease process that affects a diverse population of patients. In the elective management of this disease, treatment guidelines have shifted toward patient-centered, individualized decision-making. It is not known what challenges surgeons face as they approach these nuanced treatment decisions in practice. OBJECTIVE: This study aimed to identify opportunities to support colorectal surgeons in elective diverticulitis treatment. DESIGN: This was a qualitative study using standardized, semistructured interviews to explore the perspectives of 29 colorectal surgeons recruited using a purposive sampling technique. Data were analyzed using an "open-coding" approach. SETTINGS: Interviews with a national sample of colorectal surgeons were conducted from a single center using an online video platform. PATIENTS: This study did not involve patients. MAIN OUTCOME MEASURES: Interviews explored surgeons' experiences treating diverticulitis in the elective setting, focusing on perceived challenges in providing patient-centered care as well as opportunities to improve treatment decisions. RESULTS: Our qualitative analysis identified an overarching challenge in elective diverticulitis management for surgeons: difficulty ensuring adequate patient understanding of the risks and benefits of various treatments. This was thought to be due to 1) preexisting patient expectations about treatment and 2) lack of data regarding long-term treatment outcomes. Surgeons identified 2 potential opportunities to combat these challenges: 1) patient education and 2) additional research regarding treatment outcomes, with potential for the development of diverticulitis-specific decision support tools. LIMITATIONS: These results are based on a national sample of colorectal surgeons, but they capture qualitative data that is not intended to provide generalizable findings. CONCLUSIONS: As surgeons work toward providing individualized care for diverticulitis patients, they find it difficult to adequately counsel patients regarding the patient-specific risks of various treatments. The results of this study identify specific contributors to this problem as well as potential targets for intervention, which can guide future efforts to support surgeons in providing patient-centered care. See Video Abstract . DESAFOS Y OPORTUNIDADES EN EL MANEJO ELECTIVO DE LA DIVERTICULITIS PERSPECTIVAS DE UNA MUESTRA NACIONAL DE CIRUJANOS COLORRECTALES: ANTECEDENTES:La diverticulitis es un proceso patológico complejo y heterogéneo que afecta a una población diversa de pacientes. En el manejo electivo de esta enfermedad, las pautas de tratamiento se han desplazado hacia una toma de decisiones individualizada y centrada en el paciente. No se sabe qué desafíos enfrentan los cirujanos al abordar estas decisiones de tratamiento matizadas en la práctica.OBJETIVO:Identificar oportunidades para apoyar a los cirujanos colorrectales en el tratamiento electivo de la diverticulitis.DISEÑO:Este fue un estudio cualitativo que utilizó entrevistas semiestructuradas estandarizadas para explorar las perspectivas de 29 cirujanos colorrectales reclutados mediante una técnica de muestreo intencional. Los datos se analizaron utilizando un enfoque de "codificación abierta".ESCENARIO:Las entrevistas con una muestra nacional de cirujanos colorrectales se realizaron desde un solo centro utilizando una plataforma de video en línea.PRINCIPALES MEDIDAS DE RESULTADO:Las entrevistas exploraron las experiencias de los cirujanos en el tratamiento de la diverticulitis en el entorno electivo, centrándose en los desafíos percibidos en la prestación de atención centrada en el paciente, así como en las oportunidades para mejorar las decisiones de tratamiento.RESULTADOS:Nuestro análisis cualitativo identificó un desafío general en el manejo de la diverticulitis electiva para los cirujanos: la dificultad para asegurar que el paciente comprenda adecuadamente los riesgos y beneficios de los diversos tratamientos. Se pensó que esto se debía a 1) las expectativas preexistentes del paciente sobre el tratamiento y 2) la falta de datos sobre los resultados del tratamiento a largo plazo. Los cirujanos identificaron dos oportunidades potenciales para combatir estos desafíos: 1) educación del paciente y 2) investigación adicional sobre los resultados del tratamiento, con potencial para el desarrollo de herramientas de apoyo a la toma de decisiones específicas para la diverticulitis.LIMITACIONES:Estos resultados se basan en una muestra nacional de cirujanos colorrectales, pero capturan datos cualitativos que no pretenden proporcionar hallazgos generalizables.CONCLUSIONES:A medida que los cirujanos trabajan para brindar atención individualizada a los pacientes con diverticulitis, les resulta difícil aconsejar adecuadamente a los pacientes sobre los riesgos específicos de los pacientes para los diversos tratamientos. Los resultados de este estudio identifican contribuyentes específicos a este problema, así como objetivos potenciales para la intervención, que pueden guiar los esfuerzos futuros para ayudar a los cirujanos a brindar atención centrada en el paciente. (Traducción-Dr. Felipe Bellolio ).

Smoking and Alcohol Consumption and Risk of Incident Diverticulitis in Women.

BACKGROUND & AIMS: Much of what is known about the effects of alcohol and tobacco use on diverticular disease derives from studies of asymptomatic diverticulosis or complicated diverticulitis. We examined smoking and alcohol consumption and risk of incident diverticulitis in a large cohort of women. METHODS: We conducted a prospective study of 84,232 women in the Nurses' Health Study II (NHS II) who were 39-52 years old and without known diverticulitis at baseline in 2003. Smoking was ascertained every 2 years and alcohol use every 4 years. We used Cox proportional hazards regression to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (CIs). RESULTS: During 1,139,660 person-years of follow up, we identified 3018 incident cases of diverticulitis. After adjustment for other risk factors, current (HR, 1.20; 95% CI, 1.04-1.39) and past smoking (HR, 1.20; 95% CI, 1.11-1.30) were associated with increased risk of diverticulitis when compared with never smokers. Women who consumed ≥30 g/d of alcohol had a multivariate HR of 1.26 (95% CI, 1.05-1.50) when compared with women who did not drink. A joint analysis of smoking and alcohol found that individuals who ever smoked and consumed ≥15 g/d of alcohol were at highest risk of diverticulitis (multivariate HR, 1.60; 95% CI, 1.16-2.21), compared with participants who never smoked and reported no alcohol use. CONCLUSIONS: In this large prospective study of women, smoking and alcohol consumption were associated with an increased risk of incident diverticulitis. These data highlight additional modifiable risk factors for diverticulitis that may aid in prevention.

Quality of life after sigmoid diverticulitis: A review.

INTRODUCTION: Diverticular disease, including diverticulitis, begins when the patient becomes symptomatic. Sigmoid diverticulitis corresponds to inflammation/infection of a diverticulum of the sigmoid colon. Among diverticulosis patients, 4.3% develop diverticulitis, a frequent pathology that can entail major functional disorders. Following sigmoid diverticulitis, few studies have assessed functional disorders and quality of life, a multidimensional concept comprising physical, psychological and mental dimensions, as well as social relations. OBJECTIVE: The purpose of this work is to report current published data on the quality of life of patients having had sigmoid diverticulitis. RESULTS: Following uncomplicated sigmoid diverticulitis, long-term quality of life does not substantially differ between patients having undergone antibiotic therapy and those having only received symptomatic treatment. As for patients having experienced recurrent events, their quality of life seems improved by elective surgery. Following Hinchey I/II sigmoid diverticulitis, elective surgery seems to improve quality of life, notwithstanding a 10% risk of postoperative complications. Following sigmoid diverticulitis, while emergency surgery seems not to have greater impact on quality of life than elective surgery, the surgical technique employed in an emergency setting seems to have an impact, particularly with regard to the physical and mental components of quality of life. CONCLUSION: Assessment of quality of life is of fundamental importance in diverticular disease and should orient operative indications, particularly in an elective context.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database.

BACKGROUND: Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies. STUDY DESIGN: We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012-2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL. RESULTS: In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70-0.96], ABP [0.69, 95%CI: 0.52-0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51-0.86], ABP [0.56, 95%CI: 0.34-0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50-0.67; AL:OR = 0.46, 95%CI:0.36-0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13-0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37-0.69], AL [OR = 0.47, 95%CI: 0.25-0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47-0.72, AL [OR = 0.49, 95%CI: 0.35-0.68]). CONCLUSIONS: MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

First episode of uncomplicated diverticulitis does not increase the risk of colorectal cancer.

INTRODUCTION: Danish guidelines recommend colonoscopy after a case of acute diverticulitis to exclude colorectal cancer (CRC), but evidence in support this practice is limited. A series of studies has reported a low incidence of CRC in patients after they presented with acute diverticulitis, especially in uncomplicated cases. The purpose of this study was to investigate the incidence of CRC after acute diverticulitis detected during colonoscopy. METHODS: All patients seen between January 2010 and November 2017 with a first episode of acute diverticulitis and a subsequent computed tomography and colonoscopy were included. RESULTS: A total of 332 patients were included in the study. The incidence of CRC after a case of uncomplicated acute diverticulitis was 0.8%. The incidence of malignancy was 2.8% in the group of patients with complicated diverticulitis. CONCLUSIONS: This study showed a low risk of CRC after a case of acute diverticulitis and no cases of CRC in patients with uncomplicated diverticulitis without clinical symptoms of CRC. This indicates that revising guidelines in regards to follow-up after diverticulitis may be warranted. FUNDING: none. TRIAL REGISTRATION: not relevant.

Incidental Findings of Appendiceal Diverticulitis Presenting as Acute Appendicitis.

Diverticulosis of the appendix (DA) is a rare pathological finding that clinically imitates acute appendicitis and is most commonly found in adult males with chronic abdominal pain. It has a higher rate of perforation compared to acute appendicitis (84% vs 12%, P<0.01), and is consequently associated with a higher rate of mortality. Appendiceal diverticulitis has been found to have a significant association with incidental appendiceal neoplasms, therefore elective prophylactic appendectomy is recommended to prevent the risk of complications and to rule out the possibility of a coexisting neoplasm. Meticulous gross examination in addition to thorough histological examination of the entire appendectomy specimen by pathologists is essential in order to identify diverticula. We present two female patients with signs and symptoms consistent with acute appendicitis, they were found to have appendiceal diverticulitis on pathologic evaluation.

A relação entre a dieta e a fisiopatologia da diverticulite: revisão integrativa / The relation between the diet and the diverticulitis pathophysiology: an integrative review

ABSTRACT BACKGROUND: Diverticulitis is an acute inflammatory process that affects individuals with diverticular disease. Given the sharp increase in the diagnostic rate of such a pathological process, there was also an increased interest in elucidating the possible causes related to the development of this clinical condition. Among the main factors investigated, diet excels, the object of study of this integrative literature review. METHODS: After searching the virtual health library and PubMed databases, five prospective cohort studies were selected that best answered the guiding question: "Is there a relationship between diet and the incidence of diverticulitis?". RESULTS: It was observed that the high intake of red meat and the low intake of dietary fiber were the most strongly associated dietary factors with the incidence of this inflammatory process. CONCLUSION: Therefore, it is evident that choosing healthy eating habits can considerably reduce the incidence of diverticulitis and, consequently, potentially more serious complications directly related to it.

RESUMO CONTEXTO: A diverticulite é um processo inflamatório agudo que afeta indivíduos com doença diverticular. Diante do acentuado aumento da taxa diagnóstica desse processo patológico, também houve o aumento do interesse em elucidar as possíveis causas relacionadas ao desenvolvimento dessa condição clínica. Entre os principais fatores investigados, destaca-se a dieta; objeto de estudo desta revisão integrativa da literatura. MÉTODOS: Após pesquisa nas bases de dados da biblioteca virtual em saúde e PubMed, foram selecionados cinco estudos de coorte prospectivos que melhor responderam à questão norteadora "Há relação entre dieta e incidência de diverticulite?". RESULTADOS E CONCLUSÃO: Observou-se que o alto consumo de carnes vermelhas e o baixo consumo de fibra alimentar são os fatores dietéticos mais fortemente associados à incidência desse processo inflamatório. Fica evidente, portanto, que a escolha de hábitos alimentares saudáveis pode reduzir consideravelmente a incidência de diverticulite e, consequentemente, de possíveis complicações mais graves diretamente relacionadas a ela.

Outcomes of diverticulitis in patients with tobacco smoking: a propensity-matched analysis of nationwide inpatient sample.

BACKGROUND: Recent data shows a significantly increased risk of diverticulosis among smokers. There is limited data on the association between tobacco smoking and diverticulitis. We aim to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of diverticulitis patients based on tobacco smoking status. METHODS: A retrospective analysis was performed by utilizing the National Inpatient Sample database (2016 and 2017) and the International Classification of Diseases, Tenth Revision codes to identify the patients with the principal diagnosis of diverticulitis and smoking. We assessed all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of tobacco smokers vs. nonsmokers with diverticulitis. RESULTS: We identified 442,273 diverticulitis patients, of whom 96,864 were tobacco smokers, and 345,409 were nonsmokers. Between the two groups, in-hospital mortality was not significant (OR 1.09, 95% CI 0.38-2.6; P = 0.98). Tobacco smokers with diverticulitis have higher odds of lower gastrointestinal bleeding (LGIB) (OR 1.6, 95% CI 1.4-3.8; P = 0.01), peritonitis (OR 1.5, 95% CI 1.9-3.3; P = 0.00), intestinal obstruction (OR 1.6, 95% CI 2.8-7.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and shock requiring vasopressor (OR 1.5, 95% CI 1.2-2.2; P = 0.00). In tobacco smokers with complicated diverticulitis, there were higher odds of LGIB (OR 1.4, 95% CI 1.2-1.6; P = 0.00), sepsis (OR 2.1, 95% CI 1.05-4.4; P = 0.03), and colectomy (OR 1.2, 95% CI 1.1-1.2; P = 0.00). In-hospital mortality was not significant in smokers with complicated diverticulitis (OR 1.2, 95% CI 0.78-1.9; P = 0.3). CONCLUSIONS: In this propensity-matched analysis, there was no difference in in-hospital mortality between tobacco smokers vs. nonsmokers with diverticulitis. Smoking has been associated with an increased incidence of complications in diverticulitis with a higher length of hospital stay and resource utilization.

The role of quantitative radiological measures of visceral adiposity in diverticulitis.

BACKGROUND: Diverticular disease has been linked to obesity. Recent studies have assessed the role of visceral adiposity with diverticulitis and its complications. The aim of this study was to evaluate the association of quantitative radiological measures of visceral adiposity in patients with diverticulitis with vital signs, biochemistry results, uncomplicated versus complicated diverticulitis and its interventions. METHODS: A retrospective analysis of all patients with diverticulitis admitted from November 2015 to April 2018 at a single institution was performed. Data collected included demographics, vital signs, biochemistry results, CT scan findings and management outcomes. The patients were divided into uncomplicated (U) and complicated diverticulitis (C) groups. Visceral fat area (VFA), subcutaneous fat area (SFA) and VFA/SFA ratio (V/S) were measured at L4/L5 level by the radiologist. Statistical analysis was performed to evaluate the association of VFA, SFA, V/S with the parameters in both U and C groups. RESULTS: 352 patients were included in this study (U:C = 265:87). There was no significant difference in vital signs and biochemistry results in both groups. There was no significant difference in VFA, SFA, V/S ratios in both groups. In patients with V/S ratio > 0.4, they were 5.06 times more likely to undergo emergency intervention (95% CI 1.10-23.45) (p = 0.03). On multivariate analysis, a heart rate > 100 (OR 2.9, 95% CI 1.2-6.7), CRP > 50 (OR 3.4, 95% CI 1.9-6.0), WCC < 4 or > 12 (OR 2.1, 95% CI 1.2-3.6) and V/S ratio > 0.4 (OR 2.8, 95% CI 1.5-5.4) were predictive of complicated diverticulitis. CONCLUSION: The quantitative radiological measurement of visceral adiposity is useful in prognostication in patients presenting with diverticulitis.

Association of Complicated Diverticulitis With Development of De Novo Inflammatory Bowel Disease.

BACKGROUND: There has been a historic similarity in the epidemiology and pathophysiology of diverticular disease and inflammatory bowel disease (IBD). Because there are limited to no data on the role of diverticulitis as a potential risk factor for de novo IBD, we aimed to evaluate the role of diverticulitis and complicated diverticulitis as a potential predictor of IBD. METHODS: We performed a retrospective, single-center study including patients older than age 18 years who were diagnosed with diverticulitis from January 2012 until December 2018 without a prior diagnosis of IBD. These patients were then evaluated for development of IBD. Univariate and multivariate analyses were conducted to compare the characteristics and outcomes between patients who did or did not develop IBD. RESULTS: A total of 2770 patients were diagnosed with diverticulitis from 2012 until 2018. Of these patients, 17 were diagnosed with IBD, resulting in an incidence rate of 0.23% per patient-year. The incidence rate among patients who required surgery for diverticulitis was 0.44% per patient-year, and patients with complicated diverticulitis had an incidence rate of 0.91% per patient-year. Univariate analysis showed that the need for surgery related to diverticulitis (hazard ratio [HR], 6.27; P = 0.003) and complicated diverticulitis was associated with the development of IBD (HR, 14.71; P < 0.001). Multivariate analysis showed that complicated diverticulitis was the sole factor associated with IBD (HR, 10.34; P < 0.001). CONCLUSIONS: Patients with diverticulitis are at a higher risk of developing de novo IBD. This risk is highest in patients with complicated diverticulitis.

Can We Predict Surgically Complex Diverticulitis in Elective Cases?

BACKGROUND: Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE: The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN: This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS: Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS: A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS: We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES: The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS: The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS: The study was limited by its retrospective review and observational bias. CONCLUSIONS: Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).

Underlying Colorectal Cancer Was Rarely Detected After an Episode of Acute Diverticulitis: a Retrospective Analysis of 225 Patients.

PURPOSE: The aim of the present study was to determine the prevalence of underlying colorectal carcinoma (CRC) in a cohort of patients who experienced an episode of acute diverticulitis and to assess clinical and laboratory parameters that suggest CRC diagnosis. METHODS: We performed a single center retrospective study in EMMS Nazareth Hospital from April 2014 to April 2018. All Patients who experienced an episode of acute diverticulitis and underwent a colonoscopy up to 6-month period were included in the study. RESULTS: Two hundred twenty-five patients (225) patients were included. The mean age was 55.73 ± 13.81 (24-93). One hundred thirty-nine (139) patients were males. Underlying CRC was diagnosed in 2 out of 225 (0.89%) patients and colonic polyps were found in 17 out of 225 patients (7.56%). The average time interval between the episode of diverticulitis and the performance of colonoscopy was 6 weeks. Male gender was significantly associated with CRC and polyp findings (P = 0.039). Moreover, platelet count (353,000 vs. 234,000, P = 0.002) and platelet to lymphocyte ratio (223.65 vs. 127.4, P = 0.015) showed statistically significant correlation with CRC as compared to colonic polyps. CONCLUSION: The rate of underlying CRC diagnosis was extremely low after an episode of acute diverticulitis. Male gender and platelet to lymphocyte ratio were predictors for the presence of underlying CRC.

Course of the Diverticular Disease: What is changing?

In this session several critical issues in diverticular disease were considered, including "It is Symptomatic Diverticular Disease or Irritable Bowel Syndrome?", "What do determine evolution to diverticulitis, bowel habits alteration or inflammation?", and "Prevention of acute diverticulitis: Is it at all possible?". The first talking compared symptoms and laboratory findings between Symptomatic Uncomplicated Diverticular Disease  (SUDD) and Irritable Bowel Syndrome (IBS). Although both disease share some symptoms, and although IBS can occur in patients having diverticulosis,  SUDD and IBS can be differentiate using a combination of symptoms and laboratory tools. The second talking debated what are the most important risk factors for the evolution towards acute diverticulitis. Current data seem to exclude a significant role of bowel habits alteration, while inflammation seems to have a stronger role, especially in causing acute diverticulitis recurrence. The third talking analyzed about the acute diverticulitis prevention. Primary prevention seem to be little better when using mesalazine, while no definite conclusion can be drawn about the use of fiber and rifaximin. About the secondary prevention, no drugs can be currently advised due to lacking of definite results. At the same time, surgery should be advised on case-by-case basis.

Emergency Presentations of Diverticulitis.

Acute diverticulitis is a common condition that has been increasing in incidence in the United States. It is associated with increasing age, but the pathophysiology of acute diverticulitis is still being elucidated. It is now believed to have a significant contribution from inflammatory processes rather than being a strictly infectious process. There are still many questions to be answered regarding the optimal management of acute diverticulitis because recent studies have challenged traditional practices, such as the routine use of antibiotics, surgical technique, and dietary restrictions for prevention of recurrence.

Complicated Meckel's diverticulum: Presentation modes in adults.

Complicated Meckel's diverticulum represents a common etiology of acute abdomen in children. However, this condition is less frequent in adults. We reviewed the records of adult patients who underwent the surgical removal of complicated Meckel's diverticulum between 2001 and 2017 at 2 tertiary French medical centers. We then analyzed the clinical characteristics, mode of presentation, and management for all patients.The Meckel's diverticulum was resected in 37 patients (24 males and 13 females). The mean patient age was 46.1 ±â€Š21.4 years. The most common clinical presentations of complicated Meckel's diverticulum were diverticulitis (35.1%, n = 13), small-bowel obstruction (35.1%, n = 13), and gastrointestinal bleeding (29.8%, n = 11) (anemia, n = 1; hematochezia, n = 10). Age distribution was significantly different (P = .02) according to the 3 Meckel's diverticulum complications: patients with diverticulitis (P = .02) were statistically more frequently over 40 (P = .05), significantly older than patients with gastrointestinal bleeding who were more frequently <40 (P = .05). There was a preoperative diagnosis available for 15 of the 37 patients (40%). An exploratory laparoscopy was necessary to determine the cause of disease for the other 22 patients (60%). An intestinal resection was performed in 33 patients (89%) and diverticulectomy was performed in 4 patients (11%). There was heterotopic tissue found in only 6 patients (16%). Postoperative complications were as follows: 1 death by cardiac failure in a 92-year-old patient and 2 patients with postoperative wound infections. The follow-up time was 3 to 12 months.The correct diagnosis of complicated Meckel's diverticulum in adults is difficult due to the lack of specific clinical presentation. As a result, exploratory laparoscopy appears to play a central role in cases of acute abdomen with uncertain diagnosis.

Acute diverticulitis in renal transplant patients: should we treat them differently?

BACKGROUND: Current guidelines suggest that transplant patients with acute diverticulitis should be managed aggressively with early operative intervention to reduce morbidity and mortality. This study compared the treatment choices and clinical outcomes between renal transplant patients and immunocompetent patients with acute diverticulitis. METHODS: A retrospective review was performed of all patients who were admitted with acute diverticulitis between 2002 and 2015 at a single academic institution. Patient demographics, comorbidities, physiologic and radiologic disease severity, management, and disease-specific outcomes were recorded and compared between renal transplant patients and immunocompetent patients. Predictors of complications also were analyzed. RESULTS: In the study, 20 renal transplant patients and 134 immunocompetent patients were admitted for acute diverticulitis and were followed for a median time of 36 and 40 months, respectively. Patient demographics were similar between the groups. Transplant patients had significantly more comorbidities. Overall, there were no differences in physiologic disease severity or rates of elective or urgent operation, ostomy, permanent ostomy, duration of stay, 30-day readmission, disease recurrence or disease-specific complications, organ failure, or death. Among patients with complicated disease, renal transplant patients were significantly more likely to undergo an urgent operation and had more complications. On multivariate analysis, undergoing operative therapy remained the sole predictor of complications. CONCLUSION: Nonoperative management of renal transplant patients who present with uncomplicated diverticulitis is safe as outcomes are similar to immunocompetent patients. However, the optimal management of renal transplant patients with complicated diverticulitis remains unclear as both treatment choices and complication rates differed from immunocompetent patients.

Coloduodenovesical Fistula After Simultaneous Pancreas-Kidney Transplant: Case Report and Review of the Literature.

BACKGROUND: Complicated diverticulitis after transplantation occurs in as many as 3.5% of cases and carries a 25% mortality rate. Diagnosis of complicated diverticulitis in this population can be challenging because of abnormal presentations caused by immunosuppression. Only 4 cases of fistulization after kidney transplantation are described in the literature; none occurred after simultaneous pancreas-kidney transplant. METHODS: We present a first case of a coloduodenovesical fistula in a patient 9 years after simultaneous pancreas-kidney transplant. The patient presented with intermittent episodes of elevated creatinine and recurrent urinary tract infection. The presence of fistula was strongly suspected in cystoscopy, but, despite extensive investigation, a fistula tract could not be identified. RESULTS: The patient ultimately underwent surgical exploration for positive cystoscopy examination, continuation of urinary complaints, and presence of multiple colonic diverticula in computed tomography scan. At surgical exploration, a fistula track was identified between the sigmoid colon and duodenal stump of the pancreas allograft. Subsequently, sigmoidectomy, bladder repair, and enteric conversion of the pancreas transplant were performed. CONCLUSIONS: Complications of diverticulitis should be considered in organ transplant recipients presenting with recurrent urinary infection and elevated creatinine, and surgical exploration might be indicated even if unable to well-define the fistula tract.

Clinical characteristics of Meckel diverticulum in children: A retrospective review of a 15-year single-center experience.

Meckel diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract in children. The aim of this study was to review and analyze clinical data on the diagnosis and management of Meckel diverticulum in pediatric patients. The records of 102 pediatric patients (<14 years old) who underwent surgery for Meckel diverticulum at our institute between 2001 and 2015 were reviewed. Clinical, imaging, laboratory, surgical, and pathological data were recorded. The series comprised 65 males and 37 females with a median age of 5.6 years. Lower gastrointestinal bleeding was the most frequently identified clinical manifestation of Meckel diverticulum, and this manifestation was observed in 41 patients. Intussusception secondary to Meckel diverticulum was identified in 32 patients. Twelve patients presented clinical features of peritonitis; of these patients, 8 had perforated Meckel diverticulum and 4 had Meckel diverticulitis. In 10 patients, Meckel diverticulum was incidentally diagnosed during other surgeries, including appendectomy and neonatal enterostomy. Seven patients were diagnosed with intestinal obstruction. Technetium-99m pertechnetate imaging offered high diagnostic yield. Open surgery was performed on 59 patients, while a laparoscopic approach was employed in 35 patients. The remaining 8 patients did not undergo resection of the Meckel diverticulum. Histology revealed ectopic gastric mucosa in 42 patients (44.7%), ectopic pancreatic tissue in 35 patients (37.2%), mucosa of the small intestine in 15 patients (16.0%), and both gastric and pancreatic ectopic tissue in 2 patients (2.1%). All patients recovered uneventfully except 2 patients in whom an intestinal adhesion obstruction was identified after discharge. Meckel diverticulum had various clinical manifestations in children. Technetium-99m pertechnetate imaging may be useful for diagnosing Meckel diverticulum. Surgical excision of the Meckel diverticulum may be safe and effective in symptomatic patients, and relatively better outcomes can be achieved using this approach.

Tobacco smoking and the risk of diverticular disease - a systematic review and meta-analysis of prospective studies.

AIM: This systematic review and meta-analysis aimed to clarify whether tobacco smoking is associated with an increased risk of diverticular disease. METHOD: The PubMed and Embase databases were searched for studies of smoking and diverticular disease up to 19 February 2016. Prospective studies that reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of diverticular disease associated with current or previous smoking were included. Summary RRs were estimated using a random effects model. RESULTS: We identified five prospective studies which comprised 6076 cases of incident diverticular disease (diverticulosis and diverticulitis) among 385 291 participants and three studies with 1118 cases of complications related to diverticular disease (abscess or perforation) among 292 965. The summary RR for incident diverticular disease was 1.36 (95% CI 1.15-1.61, I2  = 84%, n = 4) for current smokers, 1.17 (95% CI 1.05-1.31, I2  = 49%, n = 4) for former smokers and 1.29 (95% CI 1.16-1.44, I2  = 62%, n = 5) for ever smokers. The summary RR was 1.11 (95% CI 0.99-1.25, I2  = 82%, n = 4) per 10 cigarettes per day. Although there was some indication of nonlinearity there was a dose-dependent positive association with increasing number of cigarettes smoked per day. There was some evidence that smoking also increases the risk of complications of diverticular disease, but the number of studies was small. CONCLUSION: The current meta-analysis provides evidence that tobacco smoking is associated with an increased incidence of diverticular disease and related complications.