[Actual issues of diagnosis and treatment of diverticulitis]. / Aktual'nye voprosy diagnostiki i lecheniya divertikulita.

The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.

Revisión de la clasificación de Hinchey (diverticulitis) y su correlación terapéutica / Hinchey's (Diverticulitis) classification review and it's therapeutic implacations

Resumen La diverticulosis es una entidad que predomina en países occidentales. Su prevalencia aumenta con la edad, presentándose en aproximadamente el 80% de la población mayor de 85 años. Los divertículos colónicos adquiridos son herniaciones saculares de la mucosa y submucosa (pseudodivertículos) y predominan en sigma, en países occidentales; los congénitos poseen las tres capas parietales (divertículos verdaderos) y predominan en colon derecho, en países asiáticos. Aproximadamente un 10%-25% de dichos pacientes con diverticulosis presentarán a lo largo de su vida un cuadro de diverticulitis aguda, representando una de las causas más frecuentes de abdomen agudo (3,8%). Clínicamente, se expresa por dolor abdominal en fosa ilíaca izquierda (excepción en dolicosigma/divertículos congénitos derechos) y pueden presentar complicaciones como flemones, abscesos, pileflebitis, peritonitis, con consiguiente riesgo de vida. La tomografía computada (TC) permite el diagnóstico oportuno, identificación de complicaciones y planificación terapéutica. A dicho fin se establecieron diferentes clasificaciones y modificaciones, siendo la más reconocida la propuesta por Hinchey (modificada por Wasvary y col., Kaiser y col.) y otras estableciendo correlaciones con el tratamiento, como la propuesta por Sartelli y col. El objetivo del presente estudio es realizar una revisión iconográfica de esta última (Sartelli y col.) y evaluar sus implicancias terapéuticas.

Abstract Diverticular disease is an entity with high prevalence in western countries that increases with age, and affects approximately 80% of the population over 85 years of age. Acquired colonic diverticula are saccular mucosal and submucosal herniation (pseudodiverticles) and predominate in sigma, in western countries; the congenital ones possess the three parietal layers (true diverticula) and predominate in right side colon, in Asian countries. Approximately 10%-25% of patients with colonic diverticulosis, in their lifetime will present an episode of acute diverticulitis, which represents one of the most frequent causes of acute abdominal pain (3.8%). Clinically it express by abdominal pain in the left iliac fossa (exception in dolicosigma / right congenital diverticula) and may present complications such as phlegmon, abscesses, pylephlebitis, peritonitis, life threatening conditions. Computed tomography (CT) allows timely diagnosis, identification of complications and therapeutic planning. To this end, several classifications have been used, from which Hinchey's is the most renown (modified by Wasvary et al, Kaiser et al.), and other ones establish therapeutic correlation such as the one proposed by Sartelli et al. The objective of the present study is to make an iconographic review of this last one (Sartelli et al.) and to evaluate its therapeutic implications.

Optimal Operative Strategy for Hinchey III Sigmoid Diverticulitis: A Decision Analysis.

BACKGROUND: Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life. OBJECTIVE: This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis. DESIGN: We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters. SETTING: This study measured outcomes over patients' lifetime horizon. PATIENTS: The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned. INTERVENTIONS: Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed. MAIN OUTCOME MEASURES: Quality-adjusted life years were the primary outcome measured. RESULTS: Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters. LIMITATIONS: This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published. CONCLUSIONS: Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.

Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria.

BACKGROUND: Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis. METHODS: An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents). RESULTS: The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean ± standard deviation [SD]) of 10.2 ± 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively. CONCLUSIONS: Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.

[Classification of Acute Diverticulitis for Stage-directed Therapy]. / Stadiengerechte Therapie der akuten Divertikulitis anhand der neuen Klassifikation der Divertikelkrankheit.

BACKGROUND: In recent years, there has been a significant change in the treatment recommendations for acute diverticulitis. In order to provide the right treatment to the individual patient, it is therefore important to classify the stage of the disease accurately, after taking various aspects into consideration. METHODS: Patients treated for acute diverticulitis in Würzburg University Hospital during 2010 to 2014 were included. Inclusion criteria were the presence of a computer tomography for disease classification. RESULTS: More than half of the patients examined (n = 135, 52.9%) had acute uncomplicated diverticulitis on admission; 112 (43.2%) had a covered perforation (small paracolic abscess n = 63, 24,3%; large abscess n = 49, 18,9%) and 12 (4.6%) a free perforation. In a total of 150 (57.9%) patients, this was the first episode of diverticulitis, with a covered (66.1%) or a free perforation (75.0%) occurring at a higher than average rate as the first manifestation. Nearly two-thirds (66.4%, n = 168) of patients underwent sigmoid resection during follow-up. DISCUSSION AND CONCLUSION: Despite current trends towards more conservative therapy of acute diverticulitis, sigmoid resection remains a corner stone of successful therapy throughout all types of acute diverticulitis. The indication of sigmoid resection nowadays requires profound knowledge of the individual prognosis for recurrent diverticulitis and quality of life.

Acute Jejunoileal Diverticulitis: Multicenter Descriptive Study of 33 Patients.

OBJECTIVE: Acute jejunoileal diverticulitis is a very rare and potentially serious disease affecting mostly elderly patients. The diagnosis is based on imaging but remains underrecognized. The purpose of this study is to describe the clinical and CT features and the outcomes of patients with acute jejunoileal diverticulitis. MATERIALS AND METHODS: Cases of acute jejunoileal diverticulitis managed at three French hospitals November 2005 through January 2015 were identified retrospectively. The final diagnosis relied either on a clinical and radiologic data review by a panel of experts or on surgical findings. Demographic, clinical, laboratory, and 18-month outcome data were collected. CT scans were reviewed by two radiologists who reached a consensus about the presence of an inflammatory diverticulum, evidence of complications, and presence of other bowel diverticula. RESULTS: We identified 33 cases of acute jejunoileal diverticulitis in 33 patients with a median age of 78 years, including 30 (91%) patients in whom an inflammatory diverticulum was identified at the jejunum (n = 26, 87%) or ileum (n = 4, 13%). Extraintestinal gas was seen in 10 (30%) patients and extraintestinal fluid in 11 (33%) patients. Other small-bowel diverticula were visible in all 33 patients. The diverticulitis was mild and resolved with nonoperative treatment in 22 (67%) patients and was severe in the remaining 11 (33%) patients, eight of whom required emergent surgery. CONCLUSION: Acute jejunoileal diverticulitis is a rare and usually nonserious condition that chiefly involves the jejunum. A detailed CT assessment may allow nonoperative treatment.

Long-term quality of life after conservative treatment versus surgery for different stages of acute sigmoid diverticulitis.

PURPOSE: It is controversial whether patients fare better with conservative or surgical treatment in certain stages of acute diverticulitis (AD), in particular when phlegmonous inflammation or covered micro- or macro-perforation are present. The aim of this study was to determine long-term quality of life (QoL) for AD patients who received either surgery or conservative treatment in different stages. METHODS: We included patients treated for AD at the University Hospital Grosshadern, Munich, Germany, between January 1, 2000, and December 31, 2010. Patients were classified by the Hansen and Stock (HS) classification, the modified Hinchey classification, and the German classification of diverticular disease (CDD). Pre-therapeutic staging was based on multidetector computed tomography. Long-term QoL was assessed by the Cleveland Global Quality of Life (CGQL) questionnaire, the Short Form 36 (SF-36), and the Gastrointestinal Quality of Life Index (GIQLI). Data are mean ± SEM. RESULTS: Patients with phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) had a better long-term QoL on the GIQLI when they were operated (78.5 ± 2.5 vs. 70.7 ± 2.1; p < 0.05). Patients with micro-abscess (CDD 2a) had a better long-term QoL on the GIQLI, CGQL, and the "Role Physical" scale of the SF-36 when they were not operated (GIQLI 86.9 ± 2.1 vs. 76.8 ± 1.0; p = 0.10; CGQL 82.8 ± 5.1 vs. 65.3 ± 11.0; p = 0.08; SF-36/Role Physical 100 ± 0.0 vs. 41.7 ± 13.9; p < 0.001). Patients with macro-abscess (CDD 2b) had a better long-term QoL when they were operated (GIQLI 89.3 ± 1.4 vs. 69.5 ± 4.5; p < 0.01; CGQL 80.3 ± 7.6 vs. 60.5 ± 5.8; p < 0.05; SF-36/Role Physical 95.8 ± 4.2 vs. 47.9 ± 13.6; p < 0.001). CONCLUSION: Considering long-term QoL, phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) should be treated conservatively. In patients with covered perforation, abscess size should guide the decision on whether to perform surgery later on or not. In the light of long-term quality of life, patients fare better after elective sigmoid colectomy when abscess size exceeds 1 cm.

[Diverticulitis : Domain of conservative or drug therapy?] / Divertikulitis : Domäne der konservativen bzw. medikamentösen Therapie?

Increasing interest in diverticular disease by the scientific community in the last 10-15 years has resulted in an increased number of publications. Among other things, nonevidence-based therapeutic paradigms were tested in randomized, controlled therapy studies. The importance of surgery in the therapy of diverticulitis has diminished in recent years; in particular, it has no role in the treatment of diverticulitis types 1a, 1b, and 2a according to the Classification of Diverticular Disease (CDD) treated successfully by conservative means. Surgery has only a subordinate role in recurrent type 3b diverticulitis according to the CDD. Diverticulitis is therefore increasingly treated using conservative or drug therapy. However, only the classic, established antibiotics are currently available as effective drugs for the treatment of diverticular disease. However, these are also decreasing in significance. Over 90% of patients with type 1a/1b diverticulitis can be safely treated according to current data without the use of antibiotics. It is possible that type 2a diverticulitis will also be successfully treated without antibiotics in the future. Substances such as rifaximin, mesalazine, or probiotics, which were tested above all in patients with chronic recurrent forms (CDD type 3a/3b), have not yet been established.

Aplicación de la clasificación de Neff modificada en el manejo de la diverticulitis aguda / The use of the modified Neff classification in the management of acute diverticulitis

Introducción: la diverticulitis aguda (DA) es cada vez más frecuente en los servicios de Urgencias. Es necesario un manejo seguro y eficaz con criterios de clasificación que permitan un tratamiento dirigido. Objetivo: verificar que la clasificación radiológica de Neff modificada (mNeff) asociada a criterios clínicos (síndrome de respuesta inflamatoria [SIRS] y comorbilidad) permite un manejo seguro de la DA. Material y métodos: estudio descriptivo prospectivo en una población de pacientes diagnosticados de DA mediante tomografía computarizada (TC). El protocolo consiste en la aplicación de la clasificación de mNeff y criterios clínicos de SIRS y comorbilidad que permiten tratamiento ambulatorio, ingreso, drenaje o cirugía. Resultados: el estudio comprende el periodo de febrero de 2010 a febrero de 2016, con un total de 590 episodios de DA en 271 mujeres y 319 hombres, con una edad mediana de 60 años (rango: 25-92 años). Grados de mNeff: grado 0 (408 pacientes, 70,6%): 376/408 (92%) tributarios a tratamiento domiciliario; alta 254/376 (67,5%); reconsultaron 33 pacientes y 22 reingresaron; éxito: 91%. Grado Ia (52, 8,9%): 31/52 (59,6%) tributarios a tratamiento ambulatorio; alta 11/31 (35,5%); reconsultaron ocho e ingresaron cinco. Grado Ib (49, 8,5%): cinco cirugías y dos drenajes. Grado II (30, 5,2%): diez cirugías y cuatro drenajes. Grado III (5, 0,9%): una cirugía y un drenaje. Grado IV (34, 5,9%): diez pacientes con buena evolución con tratamiento conservador; 24/34 (70,6%) fueron intervenidos; colocamos 3/34 (8,8%) drenajes percutáneos. Conclusión: la clasificación de mNeff es una clasificación segura y aplicable basada en los hallazgos radiológicos de la TC. Junto con datos clínicos y de comorbilidad, permite un mejor manejo del cuadro de DA (AU)

Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. Objective: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. Material and methods: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. Results: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. Conclusions: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD (AU)

[Diverticular disease: myths and realities]. / Enfermedad diverticular: mitos y realidades.

Diverticulosis and diverticular disease of the colon are common conditions in Western countries. The incidence and prevalence of these diseases are increasing and becoming significant for health systems. A growing body of knowledge is shifting the paradigm of the pathogenesis and treatment of diverticular disease. Low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to diverticular disease. The risk of developing diverticulitis among individuals with diverticulosis is lower than 10 to 25%. Studies indicate that diverticular disease may become a chronic disorder in some patients, not merely an acute illness. Contrary to the advice from international guidelines, studies have not shown that a high-fiber diet protects against diverticulosis. The evidence about the use of antibiotics in uncomplicated diverticulitis is sparse and of low quality. In relation to surgery, studies support a more conservative approach to prophylactic surgery in patients with recurrent disease or chronic symptoms. Finally, new pathophysiological knowledge suggests that other treatments may be useful (mesalamine, rifaximin and probiotics). However, more research is necessary to validate the safety, effectiveness and cost-effectiveness of these strategies.

Enfermedad diverticular: mitos y realidades / Diverticular disease: myths and realities

Diverticulosis and diverticular disease of the colon are common conditions in Western countries. The incidence and prevalence of these diseases are increasing and becoming significant for health systems. A growing body of knowledge is shifting the paradigm of the pathogenesis and treatment of diverticular disease. Low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to diverticular disease. The risk of developing diverticulitis among individuals with diverticulosis is lower than 10 to 25%. Studies indicate that diverticular disease may become a chronic disorder in some patients, not merely an acute illness. Contrary to the advice from international guidelines, studies have not shown that a high-fiber diet protects against diverticulosis. The evidence about the use of antibiotics in uncomplicated diverticulitis is sparse and of low quality. In relation to surgery, studies support a more conservative approach to prophylactic surgery in patients with recurrent disease or chronic symptoms. Finally, new pathophysiological knowledge suggests that other treatments may be useful (mesalamine, rifaximin and probiotics). However, more research is necessary to validate the safety, effectiveness and cost-effectiveness of these strategies.

Do Inflammatory Indices Play a Role in Distinguishing between Uncomplicated and Complicated Diverticulitis?

BACKGROUND: The usefulness of inflammatory indices in assessment of the severity of acute diverticulitis remains unestablished. The aim of this study was to determine whether inflammatory indices and hematological ratios could be utilised to differentiate between uncomplicated and complicated diverticulitis. METHODS: Hematological and inflammatory indices were recorded for each admission with CT confirmed acute diverticulitis (101 complicated, 127 uncomplicated). Cases were divided into training (n = 57) and test sets (n = 171). A classification and regression tree (CART) analysis was employed in the training set to identify optimal inflammatory marker cut-off points associated with complicated diverticulitis. Samples (test set) were then categorized as (A) greater than and (B) less than CART identified cut-off points. The predictive properties of inflammatory marker cut-off points in distinguishing severity of diverticulitis were assessed using a univariate logistic regression analysis, summary receiver operating characteristic curves and confusion matrix generation. RESULTS: C-reactive protein >109 mg/ml (OR 3.07, 95% CI 1.43-6.61, p = 0.004, area under the curve; AUC = 0.64) and white cell lymphocyte ratio (WLR) >17.72 (OR 4.23, 95% CI 1.95-9.17, p < 0.001, AUC = 0.64) were the most accurate parameters in distinguishing complicated and uncomplicated disease. WCC >21 × 109/l (p = 0.02, AUC = 0.60) and lymphocyte count >0.55 × 109/l (p = 0.009, AUC = 0.60) were less accurate. CONCLUSION: Widely used inflammatory indices are useful in the depiction of complicated diverticulitis. The indices cut-off points highlighted in this study should be considered at the time of diagnosis in combination with radiological features of complicated diverticulitis.

United States Guidelines for Diverticulitis Treatment.

Guidelines for diverticular disease management were last supported and published by the American Gastroenterology Association and the American College of Gastroenterology 2 decades ago. Guidelines have been published in other countries and by some societies. These guidelines are suggested as United States of America guidelines. In reality, they are what is practiced in Connecticut at Yale New Haven hospitals. The epidemiology and pathophysiology is described. This is still considered a dietary fiber-deficiency disease that results in high intracolonic pressure with resultant outpocketing of diverticula in the weakest point of the colon at the sites of vascular penetration with developing elastin deposition in the colon wall. The age and gender distribution is described. They are most common in the sigmoid. The guidelines of management are described according to accepted classification of the disease at all stages from onset, to early formation, to mild disease, to complicated disease, to rare specific states. The outcomes and mortality are discussed.

Role of minimally invasive surgery in the treatment of diverticular disease: an evidence-based analysis.

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. While the presence of diverticula is common, symptomatic diverticulitis is relatively uncommon, occurring in an estimated 10-30 % of patients. There is continued debate as to whether patients should undergo elective resection for diverticular disease and regarding the role of minimally invasive surgery. Since the first publication on laparoscopic colorectal procedures, the interest in minimally invasive surgery has kept growing. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. However, it still remains unclear whether laparoscopy should be recommended also for complicated sigmoid diverticulitis. The potential benefits of reduced pain and analgesic requirements, smaller scars, and shorter hospital stay but longer operative times are appealing to both patients and surgeons. Nevertheless, there many concerns regarding the time and the type of surgery. Although the role of minimally invasive surgery in the treatment of colonic diseases is progressively increased, current randomized controlled trials should demonstrate whether laparoscopic lavage, Hartmann's procedure or resection and anastomosis achieve the best results for patients. This review aimed to analyze the results of laparoscopic colonic resection for patients with uncomplicated and complicated forms of sigmoid diverticular disease and to determine what stages profit from a laparoscopic procedure and whether the approach can be performed with a low complication rate even for patients with complicated forms of the disease.

Enfrentamiento actual de la enfermedad diverticular complicada. visión del gastroenterólogo / Current approach to complicated diverticular disease by the gastroenterologist

Prevalence of colonic diverticulosis is increasing, although usually asymptomatic. Acute diverticulitis (AD)is the most frequent complications, afflicting 1-2 percent of cases in the long term. Diagnosis and classification of AD can usually be accomplished by simple clinical manifestations and laboratory tests. Ultrasonography and CT scan are the most frequently used imaging tests to confirm diagnosis and detect complications. Modifications to the classical Hinchey classification have incorporated uncomplicated AD (without abscess or perforation), the most frequent presentation, allowing to suggest therapy according to the severity of the disease. Uncomplicated AD usually has a benign course, does not require hospitalization and there is growing evidence suggesting that antibiotics are not required. Recurrence is uncommon and with low risk. The number of recurrences by itself is no more a valid criterion to indicate surgery and most patients should be managed medically, although there are no drugs with proven utility to modify the risk of recurrence. Complicated AD can be managed with intravenous antibiotics and percutaneous drainage of abscesses. Surgery is indicated in case of free perforation or diffuse peritonitis. There is a growing trend to use laparoscopic approach and perform peritoneal lavage, without resection in the emergency setting. However, many patients will require resective surgery during the follow-up. The classical paradigms that have guided the approach to colonic diverticulosis are being challenged by the lack of evidence, but the new ones still have to be constructed. For now, we must tolerate high levels of uncertainty and heterogeneity in the management of this common condition.

La diverticulosis colónica ha aumentado su frecuencia, es generalmente asintomática y se complica entre 1-2 por ciento a largo plazo, siendo la diverticulitis aguda (DA) la complicación más frecuente. El diagnóstico y categorización de la DA puede realizarse en base a las manifestaciones clínicas y exámenes de laboratorio simple. Las imágenes más utilizadas son la ecotomografía y la tomografía computada. Se han sugerido modificaciones a la clásica clasificación de Hinchey, que incorporan la DA no complicada y permiten sugerir la terapia de acuerdo a la gravedad. La DA no complicada (sin absceso ni perforación) es la presentación clínica más frecuente. Su evolución es benigna, no requiere hospitalización y existe evidencia creciente que cuestiona la utilidad de los antibióticos. La recurrencia es infrecuente y de bajo riesgo. El número de recurrencias no es un criterio válido para indicar la cirugía. La DA complicada puede manejarse con antibióticos intravenosos y drenaje percutáneo de abscesos. La cirugía está indicada en caso de perforación libre o peritonitis difusa. Existe una tendencia creciente a realizar aseo por vía laparoscópica, sin resección. La mayor parte de los pacientes con DA complicada requieren cirugía resectiva durante la evolución, mientras que aquellos con DA no complicada son de manejo médico, aunque no existen fármacos con utilidad demostrada para modificar el riesgo de recurrencia. Los paradigmas que han guiado el enfrentamiento de la diverticulosis colónica están siendo cuestionados por la falta de evidencia, por lo que, por ahora, debemos tolerar altos niveles de incerteza y heterogeneidad en el manejo de esta frecuente patología.

Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery.

BACKGROUND: Diverticular disease is one of the most common disorders of the gastrointestinal tract. 28-45% of the population develop colonic diverticula, while about 25% suffer symptoms and about 5% complications. AIM: To create formal guidelines for diagnosis and management. METHODS: Six working groups with 44 participants analyzed key questions in subject areas assigned to them. Following a systematic literature search, 451 publications were included. Consensus was obtained by agreement within the working groups, two Delphi processes and a guideline conference. RESULTS: Targeted management of diverticular disease requires a classificatory diagnosis. A new classification was created. In addition to the clinical examination, intestinal ultrasound or computed tomography is the determining factor. Interval colonoscopy is recommended to exclude comorbidities. A low-fiber diet, obesity, lack of exercise, smoking and immunosuppression have an adverse impact on diverticulosis. This can lead to diverticulitis. Antibiotics are no longer recommended in uncomplicated diverticulitis if no risk factors such as immunosuppression are present. If close monitoring is ensured, uncomplicated diverticulitis can be treated on an outpatient basis. Complicated diverticulitis should be treated in hospital, involving broad-spectrum antibiotic therapy, where necessary abscess drainage, and surgery, if possible laparoscopically. In the case of chronic relapsing diverticulitis, the risk of perforation decreases with each episode, so that surgery is no longer recommended after the second episode but only following individual assessment. CONCLUSIONS: New findings on diverticular disease call into question the overuse of antibiotics and excessive indications for surgery. Targeted treatment requires a precise diagnosis and intensive interdisciplinary cooperation.

Application of a modified Neff classification to patients with uncomplicated diverticulitis.

AIM: Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. METHOD: All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. RESULTS: Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. CONCLUSION: Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.

Appendicitis/diverticulitis: minimally invasive surgery.

Complicated intra-abdominal infections such as acute appendicitis and complicated diverticulitis represent both diagnostic and therapeutic challenges. Both diseases, although different in many ways, are caused by the obstruction of a blind pouch leading to inflammation, abscesses, and perforation of surrounding tissues. For many decades, acute appendicitis was managed through a conventional surgical incision in the right iliac fossa. As for other diseases, there is a significant tendency to propose less invasive treatments. For many teams, laparoscopy, which leads to less postoperative pain, a shorter hospital stay, and a quicker recovery, represents the standard of care for appendectomy. For selected cases, a medical approach can be proposed with satisfactory outcomes. Additionally, the management of complicated diverticulitis is also quickly moving towards less invasive procedures than the deleterious '3-phase surgery', which is Hartmann's procedure, followed by reversal protected with a stoma, and finally stoma closure. Benefiting from the evolution of antimicrobial therapy and interventional radiology, many complicated cases classified as Hinchey stage I and Hinchey stage II complicated diverticulitis are now treated medically. CT images allow the identification of patients requiring radiological drainage of localized abscesses or collections over 5 cm in size. Patients with Hinchey stage III sigmoiditis may benefit from an initial laparoscopic exploration allowing, in some cases, a conservative nonresective approach that will prevent laparotomy and stoma. Major resection leading to temporary or definitive stoma is usually indicated for stage IV complications and is required only in exceptional cases. Although a surgical intervention can be the definitive treatment for complicated intra-abdominal infections, multidisciplinary management including radiology, medical treatment, and laparoscopic surgery may limit the severe consequences of an acute surgical approach in patients suffering from complicated appendicitis and diverticulitis. Today, the ultimate goal of acutely infected abdomen management is to reduce hospital stay, disability, and numerous operations for these patients.