Diverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review.

BACKGROUND: The clinical course of diverticular disease in immunosuppressed patients is widely believed to be more severe than in the general population. In this study we systematically reviewed the literature regarding the epidemiology and clinical course of diverticulitis in immunosuppressed patients. Our goal was to develop recommendations regarding the care of this group of patients. METHODS: Using PubMed and Web of Knowledge we systematically reviewed all studies published between 1970 and 2009 that analyzed the epidemiology, clinical manifestation, or outcomes of treatment of diverticulitis in immunosuppressed patients. Keywords of "transplantation," "corticosteroid," "HIV," "AIDS," and "chemotherapy" were used. RESULTS: Twenty-five studies met our inclusion criteria. All of these studies focused on the impact of diverticulitis in patients with transplants or on chronic corticosteroid therapy. The reported incidence of acute diverticulitis in these patients was approximately 1% (variable follow-up periods). Among patients with known diverticular disease the incidence was 8%. Mortality from acute diverticulitis in these patients was 23% when treated surgically and 56% when treated medically. Overall mortality was 25%. CONCLUSIONS: Our study summarizes evidence that patients with transplants or patients on chronic corticosteroid therapy 1) have a rate of acute diverticulitis that is higher than the baseline population and 2) a mortality rate with acute diverticulitis that is high. Further research is needed to define whether these risks constitute a mandate for screening and prophylactic sigmoid colectomy.

Outpatient treatment of acute diverticulitis: rates and predictors of failure.

PURPOSE: Many patients with acute diverticulitis can be managed as outpatients, but the success rate of this approach has not been thoroughly studied. We analyzed a large cohort of patients treated on an outpatient basis for an initial episode of acute diverticulitis to test our hypothesis that outpatient treatment of acute diverticulitis is highly effective. METHODS: We analyzed patients within the Kaiser Permanente Southern California system (from 2006 to 2007) who were diagnosed with an initial episode of diverticulitis during an emergency room visit and subsequently discharged home. Each patient underwent a computed tomography (CT) scan for diagnosis or for confirmation of a diagnosis, and each radiologic report was evaluated regarding the presence of free fluid, phlegmon, perforation, and abscess. Treatment failure was defined as a return to the emergency room or an admission for diverticulitis within 60 days of the initial evaluation. RESULTS: Our study included 693 patients, of whom 54% were women, the average age was 58.5 years, and 6% failed treatment. In multivariate analysis, women (odds ratio, 3.08 [95% CI, 1.31-7.28]) and patients with free fluid on CT scan (odds ratio, 3.19 [95% CI, 1.45-7.05]) were at significantly higher risk for treatment failure. Age, white blood cell count, Charlson score, and duration of antibiotics were not significant predictive factors. CONCLUSIONS: In a retrospective analysis, among a cohort of patients who were referred for outpatient treatment, we found that such treatment was effective for the vast majority (94%) of patients. Women and those with free fluid on CT scan appear to be at higher risk for treatment failure.

Colorectal procedures: what proportion is performed by American board of colon and rectal surgery-certified surgeons?

PURPOSE: The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patient's initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile. RESULTS: We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures. CONCLUSIONS: During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by board-certified colorectal surgeons.

Decision model of segmental compared with total abdominal colectomy for colon cancer in hereditary nonpolyposis colorectal cancer.

PURPOSE: In choosing the appropriate surgical option for patients with colon cancer and Lynch syndrome, goals of treatment are to maximize life expectancy while preserving quality of life. This study constructs a decision model that encompasses these two related considerations. METHODS: We constructed a state-transition (Markov) model based on assumptions obtained from available data sources and published literature. Two strategies were considered for the treatment of colon cancer in a patient with Lynch syndrome: segmental colectomy (SEG) and total abdominal colectomy (TAC) with ileorectal anastomosis. Quality-adjusted life years (QALYs) were calculated based on utility states for patients based on the colectomy they received. Multiple sensitivity analyses were planned to examine the impact of each assumption on model results. RESULTS: For young (30-year-old) patients with Lynch syndrome, mean survival was slightly better with TAC than with SEG (34.8 v 35.5 years). When QALYs were considered, the two strategies were approximately equivalent, with QALYs per patient of 21.5 for SEG and 21.2 for TAC. With advancing age, SEG becomes a more favorable strategy. Results of our model were most sensitive to the utility state of TAC (relative to SEG), rates of metachronous occurrence, and stage of cancer at the time of such occurrence. CONCLUSION: SEG and TAC are approximately equivalent strategies for patients with colon cancer and Lynch syndrome. The decision regarding which operation is preferable should be made on the basis of patient factors and preferences, with special emphasis on age and the ability of the patient to utilize intensive surveillance.

Inflammatory bowel disease in the United States from 1998 to 2005: has infliximab affected surgical rates?

The treatment costs for patients in the United States with inflammatory bowel disease (IBD) exceed 1.7 billion dollars/year. Infliximab, an antibody to tumor necrosis factor-alpha has been extensively used to treat IBD, with 390,000 IBD patients receiving the drug since its FDA approval in 1998. We sought to determine the impact of infliximab on population-based rates of hospitalizations and surgical care for patients with IBD in the United States. We used data from the Nationwide Inpatient Sample to analyze patterns of hospital-based treatment provided to patients with IBD between 1998 and 2005. Data from this analysis were combined with census data to calculate trends in population-based rates of treatment. Overall rates of hospitalization for patients with Crohn's disease and ulcerative colitis increased significantly between 1998 and 2005 (5.1%/year and 3.4%/year respectively, P < 0.001 for each). During the same time period there were no changes in the overall rates of surgical care. The expanding use of infliximab has not significantly impacted the use of surgical procedures for patients with either ulcerative colitis or Crohn's disease, and rates of nonsurgical hospitalizations have actually increased. Even in the era of infliximab, surgical care remains a mainstay in the treatment of IBD.

Diverticulitis in California from 1995 to 2006: increased rates of treatment for younger patients.

Colonic diverticular disease is responsible for over 300,000 admissions and expenditures exceeding $2.7 billion/year. There is recent evidence that rates of treatment for diverticulitis have increased in the United States over the last decade. We hypothesize that these national trends of increasing rates of hospitalizations for diverticulitis would be found in an analysis of a single-state discharge database. Data from the Office of Statewide Health Planning and Development were used to analyze treatment for diverticulitis in California from 1995 to 2006. For each hospitalization, surgical care was determined based on procedure codes for left colon resection and/or colostomy. Overall numbers of admissions for acute diverticulitis increased throughout the 12-year study period with an estimated annual percentage of change (EAPC) of 2.1 per cent (P < 0.001). Rates of admissions increased most rapidly in patients 20 to 34-years-old (EAPC = 8.6%, P < 0.001) and 35 to 49 years old (EAPC = 5.7%, P < 0.001). Elective colectomies had an EAPC of 2.1 per cent (P < 0.001), which was also most dramatic in younger age groups. Between 1995 and 2006 we found significant increases in both the rates of hospitalization for diverticulitis and rates of elective surgical treatment in California. These increases are entirely due to higher rates of care for younger patients.

Methylnaltrexone: the answer to opioid-induced constipation?

Opioid-induced constipation is a significant problem particularly for end stage cancer patients, methadone users, patients suffering from chronic pain as well as surgical patients. Until recently, there were few efficacious treatment options that did not have significant side effects. Methylnaltrexone is a promising drug for the treatment of opioid-induced constipation. It is an opioid-receptor antagonist that blocks the peripheral gastrointestinal opioid receptors responsible for opioid-induced bowel dysfunction. Due to the drug's polarity, it does not cross the blood-brain barrier; therefore, it does not block the central opioid receptors, thus, retaining effective analgesia. Methylnaltrexone has been recently approved by the FDA in the subcutaneous form for the treatment of opioid-induced bowel dysfunction, whereas the intravenous and oral forms remain under investigation.

Candida albicans stimulates local expression of leukocyte adhesion molecules and cytokines in vivo.

The host inflammatory response to the opportunistic pathogen Candida albicans determines susceptibility to disseminated infection. This study used immunohistochemical analysis to correlate microbiologic findings and pathologic changes with local expression of cytokines and leukocyte adhesion molecules in mice with disseminated candidiasis. After being inoculated intravenously as blastospores, the organisms filamented extensively in the kidneys while remaining predominantly as blastospores or short germ tubes in the lung, liver, and spleen. Very few leukocytes accumulated around the invading organisms until 24 h after inoculation. The leukocytes at the infection site appeared to amplify the inflammatory response. They expressed interleukin-1beta, tumor necrosis factor-alpha, intercellular adhesion molecule 1, and platelet-endothelial cell adhesion molecule 1. Therefore, the morphology of the organism varies with the infection site. Furthermore, leukocyte recruitment occurs relatively late in the infection, and this recruitment is likely amplified by proinflammatory mediators produced by the leukocytes themselves.