Elective Resection Versus Observation After Nonoperative Management of Complicated Diverticulitis With Abscess: A Systematic Review and Meta-Analysis. Lamb NM, Kaiser AM. Dis Colon Rectum. 2014 Dec;57(12):1430-40.
Management of diverticulitis has evolved over the last few decades. General consensus recommends conservative management for mild disease and resective surgical management for severe disease, however the management of intermediate grade disease remains controversial. Advances in imaging technologies and image guided interventional techniques have allowed conservative, non-operative management of intermediate grade diverticulitis with antibiotic therapy and percutaneous drainage. Controversy exists regarding the need for resective surgery following diverticulitis with abscess formation after successful drainage and antibiotic management.
The study was a systematic review and meta-analysis of 22 studies, involving a total of 1051 patients, performed between 1986 and 2014 examining diverticulitis with abscess formation (Hinchey grades IB and II) managed by percutaneous drainage and antibiotic treatment. Endpoints of the study included the need for surgery and recurrent attacks without surgery. Percutaneous drainage was successful in 49% of patients with abscesses > 3cm, and antibiotic therapy alone was successful in only 14% of patients. Urgent surgery during the index hospitalization was required in 30% of patients, elective resection was performed in 36%, and no surgery was performed in 35% of patients. Overall recurrence rate was 28%. Recurrence occurred in 39% of patient awaiting elective resection, and 18% of patients managed non-operatively. Only 28% of patients were managed successfully without surgery and without recurrence.
The authors conclude that while the evidence from the literature is weak, complicated diverticulitis is associated with a high rate of recurrence and resective surgery. Conservative management may result in chronic or recurrent diverticular symptoms.
Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: a retrospective cohort study. Wilson I, Barrett MP, Sinha A, Chan S. Int J. Surg. 2014 Nov;12(11):1157-61.
The population of elderly persons is rising in many countries. As this population grows, their surgical needs will as well. Both elective and emergent procedures for the elderly are expected to increase, but emergency procedures are expected to have a greater impact in the acute care setting. This article seeks to identify risk factors that could predict in-hospital morbidity and mortality in an octogenarian population requiring emergency surgery (laparotomy). A retrospective note review of patients at least 80 years old who underwent emergency laparotomy was undertaken at a single facility over the course of 3 years (7/2008-6/2011). Vascular procedures were excluded. A total of 73 patients were identified with a mean age of 84 and a predominance of women (23:50 ratio). Morbidity and mortality in the study group (within a 30-day period) were evaluated with respect to pre-existing conditions (ischemic heart disease, diabetes, prior CVA, COPD, cancer, use of medications such as warfarin or steroids), ASA grade and timing of surgery (including decision to operate and time to ICU admission). The authors found that patients had a mean LOS of 23 days, a morbidity rate of 70% (most common being respiratory complications) and a mortality of 38%. Multivariate analysis showed that ASA grade and COPD were the only significant predictors of mortality. The authors suggest that ASA scores can be useful in discussing management and prognosis of surgical patients with the patient and families. Optimization of respiratory function in COPD patients pre and post-operatively may reduce morbidity. The use of pathways (Proactive Care of People undergoing Surgery) to assist with management of post-op complication planning and discharge planning may have a role in elective and emergent patients. Final conclusions are that a patient’s physiologic condition, in particular the ASA score and presence of COPD is more useful in predicting morbidity and mortality for patients beyond the age of 80 years rather than their actual age.
Determinants of outcome following laparoscopic peritoneal lavage for perforated diverticulitis. Radé F, Bretagnol F, Auguste M, Di Guisto C, Huten N, de Calan L. Br J Surg. 2014 Nov;101(12):1602-6.
Laparoscopy is being used more frequently in acute complicated diverticulitis. Laparoscopic peritoneal lavage is increasingly recommended for Hinchey II that is not amenable to interventional radiology drainage and Hinchey III with purulent peritonitis. This study seeks to identify patients at risk for postoperative complications, specifically additional surgical interventions. All patients with peritonitis secondary to diverticulitis who underwent laparoscopic peritoneal lavage over a 13 year period were evaluated. After excluding 9 patients who were converted to an open procedure for feculent peritonitis, 71 patients were assessed. Thirteen variables including age, American Society of Anesthesiologists (ASA) grade, body mass index, immunosuppression and pneumoperitoneum seen on imaging were collected to assess for risk of laparoscopic lavage failure. Univariable followed by multivariable analyses were performed. Eighty-five percent of the patients did not require further interventions. Eleven patients required surgery for abscess or recurrent peritonitis. The variables associated with failure of laparoscopic lavage were age ≥ 80, ASA of 3 or more, and immunosuppression. An ASA of 3 or more was associated with an odds ratio of 48.56 for laparoscopic treatment failure. The authors concluded that older patients and those with multiple comorbidities or immunosuppression do poorly despite a less invasive surgical technique.