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BACKGROUND: Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS: A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (

Purpose Conservative treatment is the first-line therapy for acute colonic diverticulitis without severe complications, but treatment failure may increase hospitalization duration, medical costs, and morbidities. Usage of the modified Hinchey classification is insufficient to predict the outcome of conservative management. We aimed to investigate the clinical efficacy of the modified Hinchey classification and to evaluate predictive factors such as inflammatory markers for the failure of conservative management. Methods Patients diagnosed with right colonic diverticulitis undergoing conservative treatment at 3 hospitals between 2017 and 2019 were included. Patients were categorized into conservative treatment success (n = 494) or failure (n = 46) groups. Clinical characteristics and blood inflammatory markers were assessed. Results The conservative treatment failure group presented with more elderly patients (>50 years, P = 0.002), more recurrent episodes (P < 0.001), a higher lymphocyte count (P = 0.021), higher C-reactive protein (CRP) levels (P = 0.044), and higher modified Glasgow prognostic scores (P = 0.021). Multivariate analysis revealed that age of >50 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.27–5.08; P = 0.008), recurrent episodes (OR, 4.78; 95% CI, 2.38–9.61; P < 0.001), and higher CRP levels (OR, 1.08; 95% CI, 1.03–1.12; P = 0.001) were predictive factors for conservative treatment failure, but not the modified Hinchey grade (P = 0.159). Conclusion Age of >50 years, recurrent episodes, and CRP levels are potential predictors for conservative management failure of patients with right-sided colonic diverticulitis. Further studies are warranted to identify candidates requiring early surgical intervention.

Diverticular disease (DD) is a leading cause of hospitalizations in developed countries affecting 30-50% of individuals older than 60 years. Identified as a distinct entity since 1980, diverticular disease-associated colitis (DAC) describes the occurrence of mucosal inflammation in a colon segment affected with DD with relative sparing of the rectum and proximal colon. Its prevalence is suggested around 1.3-3.8%. Pathogenesis is multifactorial with multiple reports noting clinicopathological overlap between DAC and inflammatory bowel disease (IBD) especially in patients with granulomatous colitis. In this setting, caution should be exercised to avoid an inappropriate diagnosis of IBD. Recurrence rates and long-term outcomes of DAC are not well defined and could range from a benign course to an overt IBD. More studies are needed in order to further characterize this entity.

A 20-year-old man was diagnosed and addressed intraoperatively by resection as a case of solitary cecal diverticulum with perforation, which was indicated by radiography and ultrasonography imaging before the operation. Histological examination confirmed perforated cecal diverticulum with colonic diverticulitis; and to prevent misdiagnosis, both computed tomography and diagnostic laparoscopy should be done.

Purpose Colonic diverticulitis is uncommon in Korea, but the incidence is rapidly increasing nowadays. The clinical features and the factors associated with complications of diverticulitis are important for properly treating the disease. Methods A retrospective review of the medical records of 225 patients that were prospectively collected between October 2007 and September 2016 was conducted. Results Diverticulitis was detected mainly in men and women aged 30 to 50 years. Diverticulitis more frequently affected the right colon (n = 194, 86.2%), but age was higher in case of left colonic involvement (42 years vs. 57 years, P < 0.001). Percentages of comorbidities (65.6% vs. 23.8%, P < 0.001), complications (65.6% vs. 6.2%, P < 0.001), and surgical treatment (50.0% vs. 4.1%, P < 0.001) were significantly higher in patients with left colonic diverticulitis. In the multivariate analysis, a risk factor for complicated diverticulitis was left colonic involvement (P < 0.001; relative risk [RR], 47.108; 95% confidence interval [CI], 12.651-175.413). In complicated diverticulitis, age over 50 was the only significant risk factor for surgical treatment (P = 0.024; RR, 19.350; 95% CI, 1.474-254.023). Conclusion In patients over 50 years of age with left colonic diverticulitis, a preventive colectomy should be reconsidered as one of the options for treatment.

Diverticulitis is a common ailment that is prevalent in the developed world. As such, the management of diverticulitis places a substantial economic burden on healthcare. Research is ongoing to further elucidate both the pathogenesis of the disease, as well as ways to reduce associated expenditures. One of these emerging areas of research calls into question the use of antibiotics during treatment of acute uncomplicated diverticulitis. Current guidelines are largely based on expert opinion, with little evidence supporting the standard practice of antibiotic therapy. In this literature review, we have compiled and analyzed the latest collection of evidence in managing acute uncomplicated diverticulitis. There have been two randomized controlled trials (RCTs) performed that assessed the possibility of treating acute uncomplicated diverticulitis without antibiotics. Both the Antibiotika Vid Okomplicerad Divertikulit (AVOD) study and Daniels, et al. have found that an observational approach to acute uncomplicated diverticulitis is not inferior to antibiotic treatment and does not result in increased complication or recurrence rates. We also reviewed a single-center cohort study, a prospective observational study, and two retrospective case-controlled studies comparing observational management versus antibiotic treatment in patients with acute uncomplicated diverticulitis. We found the results were comparable; there was no difference in complication rates or recurrence in any study. The consensus among the studies reviewed challenges the current practice guidelines issued by the American Gastroenterological Association. However, given the geographical difference in diverticular disease and inherent bias found in these studies, we cannot recommend a modification of the guidelines. Based on this literature review, we feel compelled to suggest, and strongly recommend, further research be conducted in the United States in order to bolster the already significant evidence against antibiotic therapy in acute uncomplicated diverticulitis.

A 58-year-old woman presented to the emergency department with cauda equina syndrome and sepsis. The symptoms were attributed to a complicated episode of sigmoid diverticulitis. MRI showed that the diverticulitis had caused an intra-abdominal fistula to a presacrally localized abscess expanding into the spinal canal, compressing the cauda equina nerves. Although Hartmann's procedure was performed, the neurological symptoms persisted, causing the patient to remain partially paraplegic. This case report illustrates that cauda equina syndrome is a condition that can also be caused by intra-abdominal pathology such as diverticulitis.

Article, 信州医学雑誌 61(1):19-25(2013)

Background Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis. Methods A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality. Results Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality. Conclusion Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Colonic diverticulitis (CD) is a common entity whose diagnosis is particularly based on computed tomography (CT) examination, which is the imaging technique of choice. However, unusual CT findings of CD may lead to several difficulties and potential pitfalls: due to technical errors in the management of the CT examination, due to the anatomical situation of the diseased colon, in diagnosing unusual complications that may concern the gastrointestinal tract, intra- and retroperitoneal viscera or the abdominal wall, and in differentiating CD from other abdominal inflammatory and infectious conditions or colonic cancer. The aim of this work is to delineate the pitfalls of CT imaging and illustrate misleading CT features in patients with suspected CD.

SUMMARY Diverticular disease of the colon is a disease that mainly affects the elderly and presents in 50–70% of those aged 80 years or older. The most common complication is colonic diverticulitis. Eighty percent of patients who present with colonic diverticulitis are aged 50 years and older. Diagnosis and treatment of colonic diverticulitis in the elderly is more difficult and complicated owing to more comorbid conditions. Computed tomography is recommended for diagnosis when colonic diverticulitis is suspected. Most patients admitted with acute colonic diverticulitis respond to conservative treatment, but 15–30% of patients require surgery. Because surgery for acute colonic diverticulitis carries significant rates of morbidity and mortality, conservative treatment is recommended in the elderly. Conservative treatment of colonic diverticulitis with antibiotics, bowel rest, possibly including parenteral alimentation, is usually applied for 1–2 weeks. In the absence of a response to conservative treatment, frequent recurrence or complications (abscesses, fistulas, bowel obstructions, and free perforations), surgery is indicated.

© 2015 Elsevier Inc. Background: There is a controversy regarding the best urgent surgical treatment of colonic diverticulitis. We sought to compare outcomes of patients who underwent surgery for diverticulitis by the type of admission. Methods: The National Surgical Quality Improvement Program databases were used to examine the clinical data of patients who underwent colorectal resection for diverticulitis during 2012 to 2013. Multivariate regression analysis was performed to identify outcomes of patients. Results: We sampled a total of 13,510 patients admitted for diverticulitis who underwent colorectal resection, of which 7.8% had emergent and 19.7% had urgent operation. Patients with perforation (adjusted odds ratio [AOR] 188.56, P < .01) and preoperative sepsis (AOR 28.17, P < .01) had significantly higher rates of emergent surgery. Patients who underwent emergent operation had higher mortality (AOR 4.08, P = .04) and morbidity (AOR 2.14, P < .01). Emergent operations had a significantly higher risk of anastomosis leakage compared with elective operation (AOR 3.92, P = .02). Conclusions: Emergent treatment of diverticulitis is associated with a high morbidity and mortality. In the setting of emergent treatment of diverticulitis, colonic anastomosis without a stoma has a high risk of anastomosis leakage.

Purpose This study included all patients treated at the University Hospital of Geneva for a first episode of uncomplicated diverticulitis. Risks of recurrence and treatment failure were evaluated by comparing the results between short-course and long-course intravenous (IV) antibiotic therapy groups. Methods The records of all patients hospitalized at our facility from January 2007 to February 2012 for a first episode of uncomplicated diverticulitis (Hinchey Ia), as confirmed by computed tomography, were prospectively collected. We published an auxiliary analysis from this registered study at Clinicaltrials.gov (identifier number: NCT01015378). Two groups of patients were considered: one received a short-course IV antibiotic arm (ceftriaxone and metronidazole) for up to 5 days (followed by 5 days of oral antibiotics); the other received a long-course IV arm between days 5 and 10. The primary outcome was the recurrence-free survival time. Results Follow-up was completed for 256 patients-50% men and 50% women, with a median age of 56 years (range, 24-85 years). The average follow-up was 50 months (range, 19-89 months). Of the 256 patients included in the study, 46 patients received a short-course IV antibiotic treatment and 210 received a long-course treatment. The recurrence-free survivals were very similar between the two groups, which was supported by a log rank test (P = 0.772). Four treatment failures, all in the long-course IV antibiotic treatment group, occurred. Conclusion Treatment of diverticulitis with a short IV antibiotic treatment is possible and does not modify the recurrence rate in patients with uncomplicated diverticulitis.

Colonovesical fistula is one of the serious complications of colonic diverticulitis. We herein report four cases of colonovesical fistula due to colonic diverticulitis. There were 2 men and 2 women. The mean age of the patients was 62.2 years (range, 50-76 years). The main clinical presentation included pneumaturia, fever, intractable cystitis and others. Barium enema study among diagnostic modalities was most sensitive to an accurate diagnosis. Operative procedures were sigmoidectomy with or without fistulectomy. There were no severe complications after surgery. Sigmoidovesical fistula due to colonic diverticulitis should be included in a differential diagnosis in patients with pneumaturia, intractable cystitis, fever and others. Sigmoidectomy may be a treatment of choice., 論文

Background Laparoscopic lavage has recently emerged as a promising alternative to sigmoid resection in the treatment of perforated diverticulitis. This study examined an early experience with this technique. Methods The files of all patients with complicated diverticulitis were searched in 34 teaching hospitals of the Netherlands. Patients with perforated diverticulitis treated with laparoscopic lavage between 1 January 2008 and 31 December 2010 were included. Results Treatment with laparoscopic lavage was performed in only 38 patients in ten hospitals. Lavage was successful in controlling sepsis in 31 of the 38 included patients, with 32 per cent morbidity (10 of 31 patients) and fast recovery. Overall, 17 of 38 patients developed complications, of whom two had a missed overt sigmoid perforation. Two patients died from multiple organ failure and one from aspiration pneumonia; one other patient died after palliative management of inoperable lung carcinoma. Three patients in whom lavage was successful underwent subsequent sigmoid resection for recurrent diverticulitis. Patients in whom lavage was unsuccessful tended to have more co-morbidities, a higher preoperative C-reactive protein concentration and a higher Mannheim Peritonitis Index. Conclusion Laparoscopic lavage for perforated diverticulitis was feasible in the majority of patients, but identification of an overt sigmoid perforation and patient selection are of critical importance. © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Purpose This study assessed optimal management of colonic diverticulitis as functions of disease location and severity and factors associated with complicated diverticulitis. Methods This retrospective review analyzed 202 patients diagnosed between 2007 and 2014 at Chonbuk National University Hospital, South Korea, with colonic diverticulitis by using abdominopelvic computed tomography. Diverticulitis location was determined, and disease severity was categorized using the modified Hinchey classification. Results Patients included 108 males (53.5%) and 94 females (46.5%); of these, 167 patients (82.7%) were diagnosed with right-sided and 35 (17.3%) with left-sided colonic diverticulitis. Of the 167 patients with right-sided colonic diverticulitis, 12 (7.2%) had complicated and 155 (92.8%) had uncomplicated diverticulitis; of these, 157 patients (94.0%) were successfully managed conservatively. Of the 35 patients with left-sided colonic diverticulitis, 23 (65.7%) had complicated and 12 (34.3%) had uncomplicated diverticulitis; of these, 23 patients (65.7%) were managed surgically. Among patients with right-sided diverticulitis, those with complicated disease were significantly older (54.3 ± 12.7 years vs. 42.5 ± 13.4 years, P = 0.004) and more likely to be smokers (66.7% vs. 32.9%, P = 0.027) than those with uncomplicated disease. However, among patients with left-sided diverticulitis, those with complicated disease had significantly lower body mass index (BMI; 21.9 ± 4.7 kg/m2 vs. 25.8 ± 4.3 kg/m2, P = 0.021) than those with uncomplicated disease. Conclusion Conservative management may be effective in patients with right-sided diverticulitis and patients with uncomplicated left-sided colonic diverticulitis. Surgical management may be required for patients with complicated left-sided diverticulitis. Factors associated with complicated diverticulitis include older age, smoking and lower BMI.

Multidetector computed tomography (MDCT) cystography currently represents the modality of choice to image the urinary bladder in traumatized patients. In this review we present our experience with MDCT cystography applications outside the trauma setting, particularly for diagnosing bladder fistulas and leaks. A detailed explanation is provided concerning exam preparation, acquisition technique, image reconstruction and interpretation. Colovesical fistulas most commonly occur as a complication of sigmoid diverticular disease, and often remain occult after extensive diagnostic work-up including cystoscopy and contrast-enhanced CT. We consistently achieved accurate preoperative visualization of colovesical fistulas using MDCT cystography. Urinary leaks and injuries represent a non-negligible occurrence after pelvic surgery, particularly obstetric and gynaecological procedures: in our experience MDCT cystography is useful to investigate iatrogenic bladder leaks or fistulas. In our opinion, MDCT cystography should be recommended as the first line modality for direct visualization or otherwise confident exclusion of both spontaneous enterovesical fistulas and bladder injuries following instrumentation procedures, obstetric or surgical interventions. Main Messages • Explanation of exam preparation, acquisition technique, image reconstruction and interpretation. • Preoperative visualization of colovesical fistulas, usually secondary to sigmoid diverticulitis. • Visualization or exclusion of iatrogenic bladder injuries following instrumentation or surgery.

Objetivo: valorar el uso precoz de la tomografía computarizada (TC) para el diagnóstico, estadificación y manejo de la diverticulitis aguda. Material y métodos: realizamos un estudio prospectivo de 102 pacientes con el diagnóstico clínico de diverticulitis aguda de colon izquierdo. La diverticulitis aguda fue inicialmente dividida en tres estadios. Los pacientes fueron reestadiados en los estadios I, IIa, IIb y III de acuerdo a los hallazgos encontrados en la TC. El diagnóstico se confirmó después intraoperatoriamente, por colonoscopia o estudio con bario. Resultados: fueron incluidos 102 pacientes (52 mujeres y 50 hombres) con una edad media de 59,4 (DS ± 14,96). En 84 (82,35%) pacientes con el diagnóstico clínico de diverticulitis aguda se confirmó este diagnóstico con un error diagnóstico del 17,65% (n = 18). La diverticulitis aguda se diagnosticó con la TC en el 84,3% (n = 86). La TC tuvo una sensibilidad del 100% y especificidad del 88,9%. La TC cambió la estadificación clínica en un 38% debido a una infraestadificación del 13% y una sobreestadificación del 25%, que llega al 60 y al 50% en los estadios clínicos II y III, respectivamente. La reclasificación o reestadificación de los pacientes de acuerdo con los hallazgos en la TC tiene una consecuencia importante en la indicación quirúrgica. Conclusiones: la estadificación clínica precoz de la diverticulitis con la TC evita errores de diagnóstico clínico en el 17,65%. La TC modifica la estadificación clínica de severidad en el 38% evitando la cirugía innecesaria y el retraso en el tratamiento quirúrgico. Objectives: to assess the early use of CT for the diagnosis, staging, and management of acute diverticulitis. Materials and methods: a prospective study of 102 patients with a clinical diagnosis of acute diverticulitis of the left colon. Acute diverticulitis was initially divided into 3 clinical stages. Patients were restaged according to CT findings into stages I, IIa, IIb, and III. Diagnosis was subsequently confirmed intraoperatively or by colonoscopy or barium studies. Results: 102 patients (52 females and 50 males, mean age of 59.4 (SD + 14.96 years)) were included; 84 (82.35%) patients with a clinical diagnosis of acute diverticulitis were confirmed to suffer this disease for a diagnostic error of 17.65% (n=18). Acute diverticulitis was diagnosed by CT in 84.3% (n=86). CT had a sensitivity of 100% and a specificity of 88.9%. CT changed clinical stage for 38% of patients - because of understaging in 13% and of overstaging in 25%. When stages II and III were analyzed separately, 60 and 50% were overstaged, respectively. The reclassification of patients according to CT results had a significant impact on treatment. Conclusions: Early clinical staging with CT avoids diagnostic clinical errors in 17.65% of patients. CT changes the initial clinical staging of acute episodes in 38% of cases, thus avoiding unnecessary delays in surgery for severe cases, and unnecessary surgeries for mild cases.

Purpose The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery. Methods We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode. Results Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated with elective surgery had a higher rate of stoma than patients treated non-operatively (7.2% vs. 1.4%; P = 0.028); this difference was not observed in the subgroup of patients with CAD (15.3% vs. 6.8%; P = 0.458). Conclusion After an episode of AD, nonoperative management is safe because fewer than 5% of patients will need an emergent procedure in a subsequent attack of AD. A first episode of CAD is the only risk factor for emergency surgery in patients managed conservatively.