Diverticular disease of the colon.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

/pdf/2020-update-of-the-wses-guidelines-for-the-management-of-537ft2tuxr.pdf

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

In order to elaborate evidence-based, national Danish guidelines for the treatment of diverticular disease the literature was reviewed concerning the epidemiology, staging, diagnosis and treatment of diverticular disease in all its aspects. The presence of colonic diverticula, which is considered to be a mucosal herniation through the intestinal muscle wall, is inversely correlated to the intake of dietary fibre. Other factors in the genesis of diverticular disease may be physical inactivity, obesity, and use of NSAIDs or acetaminophen. Diverticulosis is most common in Western countries with a prevalence of 5% in the population aged 30-39 years and 60% in the part of the population > 80 years. The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5-4/100,000. Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis. Complicated diverticulitis is staged by the Hinchey classification 1-4 (1: mesocolic/pericolic abscess, 2: pelvic abscess, 3: purulent peritonitis, 4: faecal peritonitis). Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and/or CRP; but the clinical diagnosis is not sufficiently precise. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The distinction between Hinchey 3 and 4 is done by laparoscopy or, when not possible, by laparotomy. Uncomplicated diverticulitis is treated by conservative means. There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis, but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection. Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics. When the abscess is < 3 cm in diameter, drainage may be unnecessary, and only antibiotics should be instituted. The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies: The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or, alternatively, resection of the sigmoid with primary anastomosis. Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease. Evidence so far for the lavage regime is promising, comparing favourably with resection strategies, but lacking in solid proof by randomized, controlled investigations. In recent years, morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities. Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed. Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures, since prophylactic resection of the sigmoid, evaluated from present evidence, confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society. Any recommendation for routine resection following multiple cases of diverticulitis should await results of randomized studies. Laparoscopic resection is preferred in case of need for elective surgery. When malignancy is ruled out preoperatively, a sigmoid resection with preservation of the inferior mesenteric artery, oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended. Fistulae to bladder or vagina, or stenosis of the colon may be dealt with according to symptoms and comorbidity. Resection of the diseased segment of colon is preferred when possible and safe; alternatively, a diverting stoma can be the best solution.

Danish national guidelines for treatment of diverticular disease.

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.

/pdf/european-society-of-coloproctology-guidelines-for-the-1hbr6tw3ec.pdf

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

Importance Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms. Objective To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines. Evidence Review We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics:pathophysiology,natural history,medical management, andindications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. Findings Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted. Conclusions and Relevance Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.

https://jamanetwork.com/journals/JAMA/articlepdf/1814217/jrv130013.pdf

Sigmoid Diverticulitis: A Systematic Review

Diverticular disease is common, with a frequency that increases with age. Most patients with diverticulosis do not develop symptoms, though a number will develop inflammation or diverticulitis. This inflammation may develop into an abscess or free perforation. Whilst the prevalence of perforation has increased from 2.4 per 100 000 in 1986 to 3.8 per 100 000 in 2000 according to one study [1], the majority of patients with diverticulitis follow an indolent clinical course. There has been controversy, therefore, as to whether elective resection after acute diverticulitis is justified [2]. This position statement is presented in sections dealing with the pathology, symptomatology and investigation of diverticular disease and its consequences. It then examines the evidence and indications for surgical intervention and its timing. The issue of laparoscopic versus open resection is then considered. The evidence is briefly summarized under the heading ‘Findings’ and this is followed where relevant by ‘Recommendations’.

ACPGBI position statement on elective resection for diverticulitis.

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ACPGBI position statement on elective resection for diverticulitis.