Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis.

BACKGROUND: Two RCTs (AVOD and DIABOLO) demonstrated no difference in recovery or adverse outcomes when antibiotics for acute uncomplicated diverticulitis were omitted. Both trials showed non-significantly higher rates of complicated diverticulitis and surgery in the non-antibiotic groups. This meta-analysis of individual-patient data aimed to explore adverse outcomes and identify patients at risk who may benefit from antibiotic treatment. METHODS: Individual-patient data from those with uncomplicated diverticulitis from two RCTs were pooled. Risk factors for adverse outcomes and the effect of observational management were assessed using logistic regression analyses. P < 0·025 was considered statistically significant owing to multiple testing adjustment. RESULTS: In total, 545 patients in the observational group and 564 in the antibiotics group were included. No statistical differences were found in 1-year follow-up rates of ongoing diverticulitis (7·2 versus 5·0 per cent in observation versus antibiotics groups respectively; P = 0·062), recurrent diverticulitis (8·6 versus 9·6 per cent; P = 0·610), complicated diverticulitis (4·0 versus 2·1 per cent; P = 0·079) and sigmoid resection (5·0 versus 2·5 per cent; P = 0·214). An initial pain score greater than 7, white blood cell count exceeding 13·5 × 109 /l and previous diverticulitis at presentation were risk factors for adverse outcomes. Antibiotic treatment did not prevent adverse outcomes in patients at high risk of adverse events. CONCLUSION: Observational management of acute uncomplicated diverticulitis is safe. Some statistical uncertainty remains, depending on the thresholds of clinical relevance, owing to small differences, but no subgroup that would benefit from antibiotic treatment was apparent.

ANTECEDENTES: Dos ensayos clínicos aleatorizados y controlados (randomized controlled trials, RCTc) (AVOD y DIABOLO) no mostraron diferencias en la recuperación ni en los resultados adversos al tratar la diverticulitis aguda no complicada sin antibióticos. Ambos ensayos mostraron tasas más altas, estadísticamente no significativas, de diverticulitis complicada y cirugía en los grupos sin antibióticos. Este metaanálisis de datos individuales de pacientes tuvo como objetivo explorar resultados adversos e identificar pacientes en riesgo que pudieran beneficiarse del tratamiento con antibióticos. MÉTODOS: Se agruparon los datos individuales de pacientes con diverticulitis no complicada de dos RCT. Los factores de riesgo para los resultados adversos y el efecto del tratamiento observacional (sin antibióticos) se evaluaron mediante un análisis de regresión logística. Una P < 0,025 se consideró estadísticamente significativa debido al ajuste de múltiples comparaciones. RESULTADOS: En total, se incluyeron 545 pacientes en el grupo de observación y 564 pacientes en el grupo de tratamiento antibiótico. No se encontraron diferencias estadísticamente significativas (observación versus antibióticos, respectivamente) en el seguimiento a 1 año en los porcentajes de diverticulitis persistente (7,2% versus 5,0%; P = 0,062), diverticulitis recurrente (8,6% versus 9,6%; P = 0,610), diverticulitis complicada (4,0% versus 2,1%; P = 0,079) y resección sigmoidea (5,0% versus 2,5%; P = 0,214). Una puntuación de dolor inicial > 7, un recuento leucocitario > 13,5 x 109 /L y los antecedentes de diverticulitis fueron factores de riesgo para un resultado adverso. El tratamiento con antibióticos no previno los resultados adversos en pacientes con alto riesgo. CONCLUSIÓN: El tratamiento de la diverticulitis aguda no complicada basado en la observación es seguro. No obstante, persiste una cierta incertidumbre desde el punto de vista estadístico, dependiendo de los umbrales de relevancia clínica, debido a pequeñas diferencias, pero no fue evidente ningún subgrupo que se pudiera beneficiar del tratamiento con antibióticos.

Elective surgery should be considered after successful conservative treatment of recurrent diverticular abscesses.

Purpose: The purpose of this study was to evaluate the disease pattern and treatment of diverticular abscesses.Methods: Patients treated for diverticulitis (K57) in Västmanland, Sweden were identified for this retrospective population-based study between January 2010 and December 2014. Patients with diverticular abscesses were included. The clinical and radiological data were extracted, and the computed tomography scans were reevaluated.Results: Of the 75 patients (45 women) with a median age of 62 years (range: 23-88 years), abscesses were localized pericolic in 42 patients (59%) and in the pelvis in 33 patients (41%). The median abscess size was 4.8 cm (range: 1.1-11.0 cm). Six patients (8%) required urgent surgical intervention during the index admission. The median follow-up time was 58 months (range: 0-95 months). During follow-up, 40 patients (58%) had disease recurrence and 35 of these patients (88%) presented with complicated diverticulitis. The median time until re-admission was 2 months (range: 3 days-94 months). Patients with pelvic abscesses developed fistulas more frequently, 3 versus 11 patients (p = .003). Twenty-three percent of patients with pericolic abscesses required surgery compared with 40% of patients with pelvic abscesses (p = .09). No patients had a recurrence of abscesses after a colonic resection.Conclusion: The majority of patients with diverticular abscesses had recurrences with repeated admissions regardless of abscess location. An unexpectedly high proportion of patients required surgical intervention during the follow-up period. A liberal approach regarding elective surgery for patients with recurrent diverticulitis abscesses who tolerate surgery seems justified.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon.

AIM: The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS: The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS: This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION: This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis.

BACKGROUND: The aim of this study was to assess the long-term results in patients with uncomplicated diverticulitis who had participated in the Antibiotics in Acute Uncomplicated Diverticulitis (AVOD) RCT, which randomized patients with CT-verified left-sided acute uncomplicated diverticulitis to management without or with antibiotics. METHODS: The medical records of patients who had participated in the AVOD trial were reviewed for long-term results such as recurrences, complications and surgery. Quality-of-life questionnaires (EQ-5D™) were sent to patients, who were also contacted by telephone. Descriptive statistics were used for the analysis of clinical outcomes. RESULTS: A total of 556 of the 623 patients (89·2 per cent) were followed up for a median of 11 years. There were no differences between the no-antibiotic and antibiotic group in recurrences (both 31·3 per cent; P = 0·986), complications (4·4 versus 5·0 per cent; P = 0·737), surgery for diverticulitis (6·2 versus 7·1 per cent; P = 0·719) or colorectal cancer (0·4 versus 2·1 per cent; P = 0·061). The response rate for the EQ-5D™ was 52·8 versus 45·2 per cent respectively (P = 0·030), and no differences were found between the two groups in any of the measured dimensions. CONCLUSION: Antibiotic avoidance for uncomplicated diverticulitis is safe in the long term.

ANTECEDENTES: El objetivo de este estudio fue evaluar los resultados a largo plazo con respecto a las recidivas, las complicaciones, la cirugía y la calidad de vida (quality of life, QOL) en pacientes con diverticulitis no complicada que participaron en el ensayo clínico aleatorizado Antibióticos en la Diverticulitis Aguda no Complicada (Antibiotics in Acute Uncomplicated Diverticulitis, AVOD). MÉTODOS: Los pacientes con diverticulitis aguda no complicada del lado izquierdo diagnosticada mediante tomografía computarizada se aleatorizaron a los tratamientos sin o con antibióticos en el ensayo AVOD (previamente publicado). Las historias clínicas de los pacientes que participaron en el ensayo se revisaron para conocer resultados a largo plazo, tales como recidivas, complicaciones y cirugía. Se enviaron cuestionarios de calidad de vida (EQ-5D) a los pacientes a los que también se contactó por teléfono. RESULTADOS: Un total de 556 de los 623 pacientes (89,2%) fueron seguidos durante una mediana de 11 años. No hubo diferencias en la recidiva (86 versus 88; P = 0,986), complicaciones (12 versus 14; P = 0,737), cirugía por diverticulitis (17 versus 20; P = 0,719) o cáncer colorrectal (1 versus 6; P = 0,061) entre el grupo sin antibióticos y el grupo con antibióticos. La tasa de respuesta para el EQ-5D fue de 163 frente a 142 (P = 0,030), y no se encontraron diferencias en ninguna de las dimensiones medidas entre los grupos sin antibióticos y con antibióticos. CONCLUSIÓN: El tratamiento de la diverticulitis no complicada evitando la administración de antibióticos fue seguro a largo plazo.

Non-operative management of perforated diverticulitis with extraluminal or free air - a retrospective single center cohort study.

OBJECTIVES: The aim of this study was to describe patient characteristics and results of non-operative management for patients presenting with computed tomography (CT) verified perforated diverticulitis with extraluminal or free air. METHODS: All patients treated for diverticulitis (ICD-10: K-57) during 2010-2014 were identified and medical records were reviewed. Re-evaluations of CT examinations for all patients with complicated disease according to medical records were performed. All patients diagnosed with perforated diverticulitis and extraluminal or free air on re-evaluation were included and characteristics of patients having immediate surgery and those whom non-operative management was attempted are described. RESULTS: Of 141 patients with perforated diverticulitis according to medical records, 136 were confirmed on CT re-evaluation. Emergency surgical intervention within 24 h of admission was performed in 29 (21%) patients. Non-operative management with iv antibiotics was attempted for 107 patients and was successful in 101 (94%). The 30-day mortality rate was 2%. The presence of a simultaneous abscess was higher for patients with failure of non-operative management compared with those that were successfully managed non-operatively (67% compared to 17%, p = .013). Eleven out of thirty-two patients (34%) with free air were successfully managed conservatively. Patients that were operated within 24 h from admission were more commonly on immunosuppressive therapy, had more commonly free intraperitoneal air and free fluid in the peritoneal cavity. CONCLUSIONS: Non-operative management is successful in the majority of patients with CT-verified perforated diverticulitis with extraluminal air, and also in one-third of those with free air in the peritoneal cavity.

CT imaging for prediction of complications and recurrence in acute uncomplicated diverticulitis.

PURPOSE: The first randomized clinical trial of antibiotics in uncomplicated diverticulitis (the AVOD study) showed no benefit of antibiotics. The aim of this study was to re-evaluate the computed tomography (CT) scans of the patients in the AVOD study to find out whether there were CT findings that were missed and to study whether CT signs in uncomplicated diverticulitis could predict complications or recurrence. METHODS: The CT scan images from patients included in the AVOD study were re-evaluated and graded by two independent reviewers for different signs of diverticulitis, including complications, such as extraluminal gas or the presence of an abscess. RESULTS: Of the 623 patients included in the study, 602 CT scans were obtained and re-evaluated. Forty-four (7 %) patients were found to have complications on the admitting CT scan that had been overlooked. Twenty-seven had extraluminal gas and 17 had an abscess. Four of these patients deteriorated and required surgery, but the remaining patients improved without complications. Of the 18 patients in the no-antibiotic group, in whom signs of complications on CT were overlooked, 15 recovered without antibiotics. No CT findings in patients with uncomplicated diverticulitis could predict complications or recurrence. CONCLUSION: No CT findings that could predict complications or recurrence were found. A weakness in the initial assessment of the CT scans to detect extraluminal gas and abscess was found but, despite this, the majority of patients recovered without antibiotics. This further supports the non-antibiotic strategy in uncomplicated diverticulitis.

Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study.

PURPOSE: The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period. METHODS: A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months. RESULTS: In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4%) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6%) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients. CONCLUSION: Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.

BACKGROUND: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up. METHODS: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. RESULTS: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881). CONCLUSION: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Use of prophylactic stoma mesh is a risk factor for developing rectus abdominis muscle atrophy.

PURPOSE: The aim of this study was to evaluate the possible risk factors for developing a parastomal hernia (PSH) in a cohort of rectal cancer patients with and without the application of a retro-muscular prophylactic mesh. The evaluated risk factors included the position of the stoma in the rectus abdominis muscle (RAM), RAM atrophy and shift of abdominal wall midline structures. METHODS: Rectal cancer patients treated with an abdominoperineal excision or Hartmann's procedure between 2002 and 2015 at Västmanland Hospital, Sweden was included. Postoperative CT examinations were retrospectively reviewed regarding the presence of PSH and RAM atrophy and for measurements such as position of the stoma in the RAM. RESULTS: 116 patients were included, with a median age of 71 years. 70 patients received a prophylactic stoma mesh. 55 patients (47%) had a parastomal hernia at three-year follow-up. Rectus abdominis muscle atrophy was significantly higher in the mesh group compared with the non-mesh group (37% vs 2%; P = 0.04). RAM atrophy was a significant independent protective factor for developing a PSH (P = 0.007; OR 0.15; 95% CI 0.03-0.55). CONCLUSION: Placement of a prophylactic retro-muscular stoma mesh resulted in a high frequency of RAM atrophy distal to the stomal aperture and patients with such atrophy had a lower risk of developing a PSH.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis.

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

Diagnostic accuracy of acute diverticulitis with unenhanced low-dose CT.

BACKGROUND: The aim of this study was to evaluate the diagnostic accuracy of unenhanced low-dose CT (LDCT) in acute colonic diverticulitis in comparison with contrast-enhanced standard-dose CT (SDCT). METHODS: All patients with clinically suspected diverticulitis who underwent LDCT followed by SDCT between January and October 2017 were evaluated prospectively. CT examinations were assessed for signs of diverticulitis, complications and other differential diagnoses by three independent radiologists (two consultants and one fourth-year resident) using SDCT as the reference method. Sensitivity and specificity were calculated and Cohen's κ coefficient was used for agreement analyses. RESULTS: Of the 149 patients included (mean age 66·7 years, M : F ratio 0·4), 107 (71·8 per cent) had imaging consistent with diverticulitis on standard CT. Sensitivity and specificity values for a diverticulitis diagnosis using LDCT were 95-99 and 86-100 per cent respectively, and respective values for identification of complications were 58-73 and 78-100 per cent. The corresponding κ values among the three readers for diagnosis were 0·984, 0·934 and 0·816, whereas κ values for complications were 0·680, 0·703 and 0·354. Of the 26 patients who presented with other causes of abdominal symptoms identified on standard CT, 23 were diagnosed correctly on LDCT. Missed cases included splenic infarction (1) and segmental colitis (2). CONCLUSION: The diagnostic accuracy of LDCT was high for the presence of acute diverticulitis. However, as signs of complicated disease can be missed using the low-dose protocol, use of LDCT as a primary examination method should not preclude SDCT when complications may be suspected.

ANTECEDENTES: Evaluar la precisión diagnóstica de la tomografía computarizada de dosis baja (low-dose computed tomography, LDCT) sin contraste frente a la TC con dosis estándar (standard-dose CT, SDCT) con contraste en la diverticulitis aguda de colon. MÉTODOS: Todos los pacientes con sospecha clínica de diverticulitis aguda de colon a los que se realizó una LDCT seguida de una SDCT entre enero y octubre de 2017 se evaluaron prospectivamente. Tres radiólogos independientes (dos consultores y un residente de cuarto año) analizaron los signos de diverticulitis, complicaciones y otros diagnósticos diferenciales, utilizando la SDCT como método de referencia. Se calculó la sensibilidad y la especificidad, utilizándose el coeficiente κ de Cohen para los análisis de concordancia entre observadores. RESULTADOS: De los 149 pacientes incluidos en el estudio (edad media 66,7 años, varón/mujer 0,4), 107 (71,8%) presentaban unas imágenes compatibles con diverticulitis en la SDCT. La sensibilidad y la especificidad para el diagnóstico de diverticulitis con la LDCT variaban entre el 95-99% y el 86-100%, respectivamente. La sensibilidad y la especificidad para la identificación de complicaciones oscilaron entre el 58-73% y el 78-100%, respectivamente. Los valores κ entre observadores para el diagnóstico fueron del 0,98, 0,93 y 0,82, respectivamente, mientras que para las complicaciones fueron del 0,68, 0,70 y 0,35. De los 26 pacientes en los que la SDCT identificó otras etiologías como causa de sus síntomas abdominales, 23 fueron diagnosticados correctamente con la LDCT. Los casos con diagnóstico erróneo correspondían a un infarto esplénico y dos colitis segmentarias. CONCLUSIÓN: La precisión diagnóstica de la LDCT fue alta para detectar una diverticulitis aguda. Sin embargo, el protocolo de dosis baja puede no identificar los signos de la enfermedad complicada. Por lo tanto, su utilización como método de exploración primario no debe excluir la SDCT cuando se sospechen complicaciones.

Micromechanical evaluation of DP1000-GI dual-phase high-strength steel resistance spot weld.

In situ micro-cantilever bending tests were carried out on resistance spot welded DP1000-GI dual-phase high-strength steel in order to derive the mechanical response of the welds. Notched micro-cantilevers were milled using focused ion beam milling at the base metal, inter-critical, fine-grained and coarse-grained heat affected zones, and fusion zone. It was shown that due to large plastic yielding, linear-elastic fracture mechanics are inapplicable. To evaluate the fracture toughness of different weld zones, cyclic loading was applied to track the crack size and the conditional fracture toughness of weld zones was measured using crack tip opening displacement and J-integral methods. It was found that micro-cantilever bending method provides insight to the fracture toughness and local mechanical response of different weld zones. The results obtained can be used to make an accurate correlation between resistance spot welding process, microstructure and mechanical response of DP1000-GI dual-phase high-strength steel welds.

Acute colonic diverticulitis: a systematic review of diagnostic accuracy.

OBJECTIVE: To appraise the literature on the diagnosis of acute colonic diverticulitis by ultrasound (US), computed tomography (CT), barium enema (BE) and magnetic resonance imaging (MRI). METHOD: The databases of Pub Med, the Cochrane Library and EMBASE were searched for articles on the diagnosis of diverticulitis published up to November 2005. Studies where US, CT, BE, or MRI were compared with a reference standard on consecutive or randomly selected patients were included. Three examiners independently read the articles according to a prespecified protocol. In case of disagreement consensus was sought. The level of evidence of each article was classified according to the criteria of the Centre for Evidence-Based Medicine (CEBM), Oxford, UK. RESULTS: Forty-nine articles relevant to the subject were found and read in full. Twenty-nine of these were excluded. Among the remaining 20 articles, only one study, evaluating both US and CT reached level of evidence 1b according to the CEBM criteria. Two US studies and one MRI study reached level 2b. The remaining studies were level 4. CONCLUSION: The best evidence for diagnosis of diverticulitis in the literature is on US. Only one small study of good quality was found for CT and for MRI-colonoscopy.