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1.
Dis Colon Rectum ; 63(2): 217-225, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31914114

RESUMO

BACKGROUND: The true incidence of, and risk factors for, readmission for treatment failure after nonoperative management of acute diverticulitis remain poorly understood. OBJECTIVE: The purpose of this study was to describe the incidence and risk factors for readmission for treatment failure after nonoperative management of acute diverticulitis using a large national database. DESIGN: This was a retrospective cohort study. SETTINGS: A representative sample of admissions and discharges from hospitals in the United States captured in the National Readmissions Database were included. PATIENTS: Adult patients (age ≥18 y) admitted with a primary diagnostic of colonic diverticulitis between 2010 and 2015 and who were managed nonoperatively and discharged from hospital alive were included. INTERVENTIONS: Study intervention included nonoperative management, consisting of medical therapy with or without percutaneous drainage. MAIN OUTCOME MEASURES: Readmission for treatment failure (defined as a nonelective readmission for diverticulitis within 90 d of discharge), complicated treatment failure (defined as a treatment failure with complicated diverticulitis), and time-to-treatment failure were measured. RESULTS: In total, 201,384 patients were included. The overall incidence of readmission for treatment failure was 6.6%. Treatment failure was significantly higher among patients with an index episode of acute complicated diverticulitis compared with acute uncomplicated diverticulitis (12.5% vs 5.7%; p < 0.001). The median time-to-readmission for treatment failure was 21.0 days (range, 20.4-21.6 d), and 85% of all readmissions occurred within 60 days of discharge. On multiple logistic regression, factors independently associated with readmission for treatment failure were an index admission of complicated diverticulitis (OR = 2.06 (95% CI, 1.97-2.16)), disposition on discharge (against medical advice: OR = 1.92 (95% CI, 1.66-2.20); home health care arrangements: OR = 1.24 (95% CI, 1.16-1.33)), and immunosuppression (OR = 1.42 (95% CI, 1.28-1.57)), among others. Risk factors for a complicated treatment failure were also described, after an index episode of complicated and uncomplicated diverticulitis. LIMITATIONS: The study was limited by residual confounding from missing covariates and its observational study design. CONCLUSIONS: The incidence of readmission for treatment failure after an episode of diverticulitis managed nonoperatively is 6.6%, and an index episode of complicated diverticulitis is the strongest risk factor for treatment failure. See Video Abstract at http://links.lww.com/DCR/B92. REINGRESO POR FRACASO DEL TRATAMIENTO DESPUÉS DEL TRATAMIENTO NO QUIRÚRGICO DE LA DIVERTICULITIS AGUDA: UN ANÁLISIS DE LA BASE DE DATOS DE REINGRESOS A NIVEL NACIONAL: La verdadera incidencia y los factores de riesgo para el reingreso por fracaso del tratamiento después de manejo no quirúrgico de la diverticulitis aguda siguen siendo mal definidos.Definir la incidencia y los factores de riesgo de reingreso por fracaso del tratamiento no quirúrgico de la diverticulitis aguda utilizando una base de datos nacional.Estudio de cohorte retrospectivo.Una muestra representativa de ingresos y egresos de hospitales en los Estados Unidos capturados en la base de datos nacional de reingresos hospitalarios.Pacientes adultos (≥18 años) ingresados con un diagnóstico primario de diverticulitis colónica entre 2010-2015, y que fueron tratados de forma no operativa y dados de alta del hospital vivos.Manejo no quirúrgico, que consiste en terapia médica con o sin drenaje percutáneo.Reingreso por fracaso del tratamiento (definido como un reingreso no electivo por diverticulitis dentro de los 90 días despues de ser dados de alta), fracaso del tratamiento complicado (definido como un fracaso del tratamiento con diverticulitis complicada) y el tiempo hasta el tratamiento en casos fracasaados.201.384 pacientes incluidos en total. La incidencia global de reingreso por fracaso del tratamiento fue del 6,6%. El fracaso del tratamiento fue significativamente mayor entre los pacientes con un episodio índice de diverticulitis aguda complicada en comparación con la diverticulitis aguda no complicada (12.5% vs. 5.7%, p <0.001). La mediana del tiempo hasta el reingreso por fracaso del tratamiento fue de 21.0 (20.4 - 21.6) días, y el 85% de todos los reingresos ocurrieron dentro de los 60 días posteriores a ser dados de alta. En la regresión logística múltiple, los factores asociados independientemente con el reingreso por fracaso del tratamiento fueron un índice de admisión de diverticulitis complicada (OR 2.06, IC 95% 1.97-2.16), disposición (de alta en contra del consejo médico: OR 1.92, IC 95% 1.66-2.2; atención médica domiciliaria: OR 1.24, IC 95% 1.16-1.33) e inmunosupresión (OR 1.42, IC 95% 1.28-1.57), entre otros. Los factores de riesgo para un fracaso del tratamiento complicado también se describieron, respectivamente, después de un episodio índice de diverticulitis complicada y no complicada.Covariables faltantes y diseño de estudio observacional.La incidencia de reingreso por fracaso del tratamiento después de un episodio de diverticulitis manejado de forma no operativa es del 6,6%, y un episodio índice de diverticulitis complicada es el factor de riesgo más fuerte para el fracaso del tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B92. (Traducción-Dr. Adrian E. Ortega).


Assuntos
Diverticulite/terapia , Administração dos Cuidados ao Paciente/tendências , Readmissão do Paciente/estatística & dados numéricos , Doença Aguda , Idoso , Bases de Dados Factuais , Diverticulite/epidemiologia , Drenagem/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Falha de Tratamento , Estados Unidos/epidemiologia
3.
J Gastrointestin Liver Dis ; 28(3): 327-337, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31517330

RESUMO

Gut microbiota composition and functionality are involved in the pathophysiology of several intestinal and extraintestinal diseases, and are increasingly considered a modulator of local and systemic inflammation. However, the involvement of gut microbiota in diverticulosis and in diverticular disease is still poorly investigated. In this review, we critically analyze the existing evidence on the fecal and mucosa-associated microbiota composition and functionality across different stages of diverticular disease. We also explore the influence of risk factors for diverticulosis on gut microbiota composition, and speculate on the possible relevance of these associations for the pathogenesis of diverticula. We overview the current treatments of diverticular disease targeting the intestinal microbiome, highlighting the current areas of uncertainty and the need for future studies. Although no conclusive remarks on the relationship between microbiota and diverticular disease can be made, preliminary data suggest that abdominal symptoms are associated with reduced representation of taxa with a possible anti-inflammatory effect, such as Clostridium cluster IV, and overgrowth of Enterobacteriaceae, Bifidobacteria and Akkermansia. The role of the microbiota in the early stages of the disease is still very uncertain. Future studies should help to disentangle the role of the microbiome in the pathogenesis of diverticular disease and its progression towards more severe forms.


Assuntos
Bactérias/crescimento & desenvolvimento , Diverticulite/microbiologia , Divertículo/microbiologia , Microbioma Gastrointestinal , Mucosa Intestinal/microbiologia , Animais , Bactérias/genética , Diverticulite/epidemiologia , Diverticulite/terapia , Divertículo/epidemiologia , Divertículo/terapia , Disbiose , Fezes/microbiologia , Interações Hospedeiro-Patógeno , Humanos , Fatores de Risco
5.
Br J Surg ; 106(8): 988-997, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31260589

RESUMO

BACKGROUND: Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT-proven acute diverticulitis. METHODS: PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT-proven left-sided acute diverticulitis. The prevalence was pooled using a random-effects model and, if possible, compared with that among asymptomatic controls. RESULTS: Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent. CONCLUSION: Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.


Assuntos
Colonoscopia , Neoplasias Colorretais/diagnóstico , Diverticulite/terapia , Doença Aguda , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/epidemiologia , Diverticulite/diagnóstico por imagem , Humanos , Prevalência , Tomografia Computadorizada por Raios X
6.
Surg Endosc ; 33(9): 2726-2741, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31250244

RESUMO

BACKGROUND: Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. METHODS: Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. RESULTS: A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members' online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. CONCLUSION: This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice.


Assuntos
Diverticulite , Endoscopia Gastrointestinal/métodos , Administração dos Cuidados ao Paciente , Doença Aguda , Diverticulite/diagnóstico , Diverticulite/terapia , Prática Clínica Baseada em Evidências , Humanos , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Seleção de Pacientes
7.
Surg Infect (Larchmt) ; 20(6): 499-503, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31066632

RESUMO

Background: Jejunal diverticulitis is rare and usually an incidental diagnosis found on imaging. Its symptoms are non-specific. Hence, the diagnosis often is delayed, and a high mortality rate has been reported. The aim of this study was to review our experience in the management of jejunal diverticulitis and to propose a management algorithm. Methods: A retrospective review of all cases of jejunal diverticulitis seen from November 2015 to November 2018 was performed. Data collected included demographics, history of diverticulitis, risk factors, clinical presentation, biochemistry and imaging results, and management outcome. Results: Eight patients were identified during the study period, five females and three males with a median age of 71 years (range 61-85 years). One patient was on steroid treatment, and one patient had a history of jejunal diverticulitis. Abdominal pain was present in all patients, but other symptoms were variable. Two patients were initially believed to have constipation and were discharged home. All patients underwent a computed tomography (CT) scan for the diagnosis, showing that three had uncomplicated jejunal diverticulitis and five had localized perforation. Five patients were managed conservatively initially; two failed this treatment because of small bowel obstruction and persistent abdominal pain with rising inflammatory markers. Three underwent emergency laparotomy (two because of sepsis; one was thought to have a foreign body). There were no deaths. A proposed management algorithm is discussed. Conclusions: A CT scan is the mainstay for the accurate diagnosis of jejunal diverticulitis. The proposed algorithm can aid in selection of patients suitable for conservative management.


Assuntos
Algoritmos , Gerenciamento Clínico , Diverticulite/diagnóstico , Diverticulite/terapia , Doenças do Jejuno/diagnóstico , Doenças do Jejuno/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X
8.
J Med Case Rep ; 13(1): 129, 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31036083

RESUMO

INTRODUCTION: Pharyngoesophageal diverticulum is an uncommon complication after anterior cervical discectomy and fusion surgery. CASE PRESENTATION: Our patient was a 48-year-old woman with two previous cervical surgeries with fixation of C4-C5 and C5-C6, the last one in 2003. Two years after surgery, she presented with arthralgia, arthritis, chills, and fluctuating rash. In 2007, she presented with dysphagia, halitosis, and sputum production. She was diagnosed with a pharyngoesophageal diverticulum with a fistula to C6 vertebra and secondary spondylitis. She was taken for open surgery with removal of screws and plates, cricopharyngeal myotomy, and esophageal repair. Streptococcus milleri grew in tissue and osteosynthetic material. She received 4 months of amoxicillin and probenecid and had a complete recovery. Since 1991, 19 similar cases have been reported with one fatality. To our knowledge, this is the first reported case of diverticulum complicated with fistula and secondary spondylitis. CONCLUSIONS: In patients with a history of anterior cervical discectomy and fusion complaining of dysphagia, even years after surgery, it is mandatory to perform an esophagogram. This symptom was referred to in 88% of the cases reported in the literature.


Assuntos
Remoção de Dispositivo , Diverticulite/diagnóstico por imagem , Complicações Pós-Operatórias/patologia , Fusão Vertebral/efeitos adversos , Espondilite/diagnóstico por imagem , Infecções Estreptocócicas/diagnóstico , Adjuvantes Farmacêuticos , Amoxicilina , Placas Ósseas/microbiologia , Parafusos Ósseos/microbiologia , Transtornos de Deglutição/diagnóstico por imagem , Diverticulite/terapia , Feminino , Humanos , Pessoa de Meia-Idade , Miotomia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/cirurgia , Probenecid , Radiografia , Espondilite/terapia , Infecções Estreptocócicas/tratamento farmacológico , Streptococcus milleri (Grupo)/isolamento & purificação , Resultado do Tratamento
9.
Rev Gastroenterol Mex ; 84(2): 220-240, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31014749

RESUMO

Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.


Assuntos
Doenças do Colo/terapia , Doenças Diverticulares/terapia , Consenso , Técnica Delfos , Diverticulite/terapia , Guias como Assunto , Humanos , México
10.
BMJ Case Rep ; 12(4)2019 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-30981989

RESUMO

We describe the case of an 82-year-old Caucasian woman who presented to our institution as a transfer from an outside hospital with nausea, vomiting and abdominal pain with CT imaging concerning for a duodenal mass or abscess in the juxtapapillary region of the second part of the duodenum. Upper endoscopy showed a non-bleeding duodenal diverticulum with purulent discharge consistent with diverticulitis. She underwent endoscopic disimpaction with irrigation and received a 14 day course of antibiotics, after which she presented for follow-up 1 month after discharge without complications. This case highlights the rarity of juxtapapillary duodenal diverticulitis, its nonspecific clinical presentation and imaging findings and the importance of early diagnosis and management to prevent severe complications including perforation.


Assuntos
Antibacterianos/uso terapêutico , Diverticulite/patologia , Duodenopatias/patologia , Dor Abdominal , Idoso de 80 Anos ou mais , Diverticulite/complicações , Diverticulite/terapia , Duodenopatias/complicações , Duodenopatias/terapia , Endoscopia , Feminino , Humanos , Náusea , Irrigação Terapêutica/métodos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Vômito
11.
Int J Colorectal Dis ; 34(6): 1087-1094, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31011868

RESUMO

INTRODUCTION: Acute uncomplicated diverticulitis (AUD) is an inflammation of the colon diverticulum. We tested the efficacy of Lactobacillus reuteri 4659 (L. reuteri) in treating AUD. Primary outcome was reduced abdominal pain and inflammatory markers (C-RP). Secondary outcome was reduced hours of hospitalization. PATIENTS AND METHODS: A double-blind, placebo RCT was conducted with 88 (34M/54F mean age 61.9 ± 13.9) patients with a diagnosis of AUD. Group A (44 patients, 26F): ciprofloxacin 400 mg/bid and metronidazole 500 mg/tid for 1 week, plus L. reuteri/bid for 10 days. Group B (44 patients, 28F): same antibiotic therapy for 1 week, plus placebo/bid for 10 days. All patients completed a daily visual analog scale (VAS) for abdominal pain. RESULTS: Between days 1 and 3, the group A pain decreased by 4.5 points; group B decreased by 2.36 points (p < 0.0001). Between days 1 and 5, the group A decreased by 6.6 points; group B by 4.4 points (p < 0.0001). Between days 1 and 7, the group A decreased by 7.6 points; group B decreased by 5.6 points (p < 0.0001). Between days 1 and 10, the group A decreased by 8.1 points; group B decreased by 6.7 points (p < 0.0001). For C-RP value, the mean decrease between admission and after 72 h was 45.3 mg/L for group A and 27.49 mg/L for group B (p < 0.0001). CONCLUSIONS: Our RCT showed that supplementation of the standard AUD therapy with L. reuteri strain 4659 significantly reduced abdominal pain and inflammatory markers compared with the placebo group. It also resulted in a shorter period of hospitalization, and thus has economic benefits. TRIAL REGISTRATION: TRIALGOV: NCT03656328.


Assuntos
Suplementos Nutricionais , Diverticulite/microbiologia , Diverticulite/terapia , Lactobacillus reuteri/fisiologia , Dor Abdominal/etiologia , Doença Aguda , Proteína C-Reativa/metabolismo , Diverticulite/complicações , Método Duplo-Cego , Feminino , Hospitalização , Humanos , Inflamação/etiologia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Placebos
14.
Dis Colon Rectum ; 62(12): 1533-1547, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30663999

RESUMO

BACKGROUND: Despite low-quality and conflicting evidence, the Association of Coloproctology of Great Britain and Ireland recommends the routine use of antibiotics in the treatment of uncomplicated acute diverticulitis. Recent studies have shown that treatment without antibiotics did not prolong recovery. Some new guidelines currently recommend selective use of antibiotics. OBJECTIVE: The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics. DATA SOURCES: PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis. STUDY SELECTION: All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included. INTERVENTION: Treatment without antibiotics versus treatment with antibiotics were compared. MAIN OUTCOME MEASURES: The primary outcome was the percentage of patients requiring additional treatment or intervention to settle during the initial episode. The secondary outcomes were duration of hospital stay, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, and complication. RESULTS: Search yielded 1164 studies. Nine studies were eligible and included in the meta-analysis, composed of 2505 patients, including 1663 treated without antibiotics and 842 treated with an antibiotic. The no-antibiotics group had a significantly shorter hospital stay (mean difference = -0.68; p = 0.04). There was no significant difference in the percentage of patients requiring additional treatment or intervention to settle during the initial episode (5.3% vs 3.6%; risk ratio = 1.48; p = 0.28), rate of readmission or deferred admission (risk ratio = 1.17; p = 0.26), need for surgical or radiological intervention (risk ratio = 0.61; p = 0.34), recurrence (risk ratio = 0.83; p = 0.21), and complications (risk ratio = 0.70-1.18; p = 0.67-0.91). LIMITATIONS: Only a limited number of studies were available, and they were of variable qualities. CONCLUSIONS: Treatment of uncomplicated acute diverticulitis without antibiotics is associated with a significantly shorter hospital stay. There is no significant difference in the percentage of patients requiring additional treatment or intervention to settle in the initial episode, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, or complications.


Assuntos
Antibacterianos/uso terapêutico , Diverticulite/terapia , Hidratação/métodos , Antibacterianos/efeitos adversos , Gerenciamento Clínico , Hidratação/efeitos adversos , Humanos , Tempo de Internação , Readmissão do Paciente/estatística & dados numéricos , Recidiva , Resultado do Tratamento
15.
Cir Cir ; 87(1): 40-44, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-30600803

RESUMO

Objective: Analyze the safety and efficacy of the outpatient treatment of uncomplicated acute diverticulitis and a costs analysis. Method: We conducted a prospective, non-randomized study between June 2014 and June 2017. We included all patients diagnosed of uncomplicated acute diverticulitis based on clinical and abdominal computed tomography scan in the Emergency Department of the University Hospital San Juan de Alicante (Spain). Outpatient treatment consisted of oral antibiotics for 7 days (amoxicillin-clavulanate or ciprofloxacin and metronidazole in patients with betalactamic allergy), liquid diet for 72 h and analgesics. Costs were evaluated according to the Law of Rates of Valencian Community. Results: Ninety patients were included, 49 females and 41 males with a median age of 56 years. Success rate was 95.5% (n = 86) requiring hospital admission 4 patients (4.5%). Antibiotic treatment was amoxicillin-clavulanate in 82 patients (91.1%) and ciprofloxacin and metronidazole in 8 (8.9%). Cost savings per patient was approximately 1985 € comparing with hypothetically all inpatient treatment. Conclusions: Outpatient treatment of uncomplicated acute diverticulitis can be performed successfully in most patients allowing an important cost savings.


Assuntos
Assistência Ambulatorial , Diverticulite/terapia , Doença Aguda , Adulto , Idoso , Diverticulite/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
16.
Tech Coloproctol ; 23(2): 87-100, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30684110

RESUMO

BACKGROUND: In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting. METHODS: A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment. RESULTS: This systematic review included 21 studies including 1781 patients who had outpatient management of AD  including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data. CONCLUSIONS: The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Diverticulite/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do Tratamento
17.
Ann Surg ; 269(4): 612-620, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30247329

RESUMO

OBJECTIVE: The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints. SUMMARY OF BACKGROUND DATA: The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up. METHODS: From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome. RESULTS: At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients. CONCLUSION: Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.


Assuntos
Colo Sigmoide/cirurgia , Tratamento Conservador , Diverticulite/terapia , Qualidade de Vida , Adulto , Diverticulite/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Tempo , Resultado do Tratamento
18.
Minerva Chir ; 74(2): 137-145, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29795067

RESUMO

INTRODUCTION: Small bowel non-Meckelian diverticulitis (SBNMD) is not so an uncommon cause of admission in departments of emergency surgery. Our aim is to highlight signs and symptoms for early diagnosis and report proper surgical treatments. EVIDENCE ACQUISITION: The systematic review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P). EVIDENCE SYNTHESIS: Twelve studies met our inclusion criteria. A total of 527 patients diagnosed with SBNMD were analyzed: there were 159 (30%) cases of diverticular bleeding, 125 (23%) cases of perforated SBNMD, 91 (17.26%) cases of intestinal obstruction, 79 (14.9%) cases of non-complicated diverticulitis, and 36 (6.8%) cases of ileal diverticulosis. Among bleeding patients, endoscopy procedures were performed in 51 (32%) cases. Surgery was necessary in 77/159 (48.4%) cases. Medical treatment was sufficient in 15/159 (9.4%) cases. In case of perforation, 93/125 (74.4%) patients were submitted to surgery, with open technique in 78/93 (83.8%) patients, by laparoscopy in 2/93 (2.1%) with conversion rate of 1.07%. Eight of 125 (6.4%) cases received medical treatment. In case of obstruction, non-operative management was effective in 3/91 (3.2%) cases. Surgery was performed in 74/91 (78%) cases, with open technique in 64/91 (86.4%) cases, by laparoscopy in 3/74 (4%), with one patient converted in laparotomy. CONCLUSIONS: Diagnosis of SBNMD is often made at emergency surgical exploration with high morbidity and mortality rate. SBNMD must be considered in elderly patients presenting with abdominal pain. A multidisciplinary approach to the patient (involving a radiologist, a surgeon, and a gastroenterologist) is necessary to make an early diagnosis. In case of complicated SBNMD, the emergency surgeon must choose the right surgical treatment.


Assuntos
Diverticulite/diagnóstico , Doenças do Íleo/diagnóstico , Intestino Delgado , Doenças do Jejuno/diagnóstico , Abdome Agudo/etiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Diverticulite/complicações , Diverticulite/terapia , Doença Diverticular do Colo , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/epidemiologia , Humanos , Doenças do Íleo/complicações , Doenças do Íleo/terapia , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/epidemiologia , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/epidemiologia , Doenças do Jejuno/complicações , Doenças do Jejuno/terapia , Masculino , Pessoa de Meia-Idade , Distribuição por Sexo , Avaliação de Sintomas , Adulto Jovem
19.
Eur J Gastroenterol Hepatol ; 31(1): 135-139, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30211720

RESUMO

OBJECTIVES: Perforated jejunal diverticulitis (PJD) is rare, but it has high mortality rates. The role of nonsurgical management is debated. The aim of this study is to assess the outcomes of medical and surgical management of PJD. PATIENTS AND METHODS: A single-centre study on a series of emergency patients diagnosed with PJD between 2010 and 2016 was conducted. RESULTS: Eleven patients with PJD were treated (seven women). Nine out of 11 were diagnosed by a computed tomography scan, and two were diagnosed at laparotomy. The initial approach was medical treatment in five patients, based on clinical and imaging findings. Four (80%) of these five patients were discharged without the need for surgical intervention. The median hospital stay was 7.5 days. Seven patients required surgery overall with a median length of hospital stay of 10.8 days. Surgical procedures consisted of segmental bowel resection and primary anastomosis in six patients and simple closure in one. There was no perioperative deaths. One patient required percutaneous drainage because of anastomotic leak, and one required reoperation owing to evisceration. DISCUSSION: Selected patients with PJD can be successfully managed with conservative approach, based on clinical and computed tomography findings.


Assuntos
Tratamento Conservador , Procedimentos Cirúrgicos do Sistema Digestório , Diverticulite/terapia , Perfuração Intestinal/terapia , Doenças do Jejuno/terapia , Idoso , Tratamento Conservador/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Diverticulite/diagnóstico por imagem , Diverticulite/cirurgia , Drenagem , Emergências , Feminino , Humanos , Perfuração Intestinal/diagnóstico por imagem , Perfuração Intestinal/cirurgia , Doenças do Jejuno/diagnóstico por imagem , Doenças do Jejuno/cirurgia , Tempo de Internação , Masculino , Complicações Pós-Operatórias/terapia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
20.
Minerva Gastroenterol Dietol ; 65(1): 42-52, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30293416

RESUMO

The incidence of diverticulosis and diverticular disease of the colon is increasing worldwide. Although the majority of patients remains asymptomatic long-life, the prevalence of diverticular disease of the colon, including acute diverticulitis, is substantial and is becoming a significant burden on National Health Systems in terms of direct and indirect costs. Fiber, non-absorbable antibiotics and probiotics seem to be effective in treating symptomatic and uncomplicated patients, and 5-aminosalicylic acid might help prevent acute diverticulitis. Unfortunately, robust evidence on the effectiveness of a medical strategy to prevent acute diverticulitis recurrence is still lacking. Focus is now being drawn on identifying a new endoscopic classification of the disease to evaluate the correct therapeutic approach by testing various treatments.


Assuntos
Divertículo/terapia , Doença Aguda , Antibacterianos/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Fibras na Dieta/administração & dosagem , Diverticulite/terapia , Divertículo/diagnóstico , Fármacos Gastrointestinais/uso terapêutico , Humanos , Mesalamina/uso terapêutico , Prevenção Primária , Probióticos/uso terapêutico , Rifaximina/uso terapêutico , Prevenção Secundária , Terminologia como Assunto
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