Enfermedad Diverticular: análisis de defunciones según sexo, grupo etario y regiones en Chile

Objetivo: Describir las defunciones por enfermedad diverticular de intestino en el período 2016 - 2020 en Chile según sexo, grupo etario y región. Material y Método: Estudio descriptivo. Se describieron 406 defunciones por enfermedad diverticular según sexo, grupo etario y región entre los años 2016-2020, realizando un análisis estadístico con el software IBM SPSS Statistics ® que incluyó una Prueba Binomial para análisis de defunciones según "sexo" y la Prueba de Kruskal Wallis para el estudio de significancia entre las variables "sexo" y "grupo etario". Se utilizó un intérvalo de confianza del 99% (p < 0,01). Resultados: se obtuvo una tasa de mortalidad 0,46/100.000 habitantes para el período estudiado. El sexo femenino fue predominante con una relación cercana a 3:1 (p < 0,01). Las defunciones aumentaron con la edad y el grupo etario con mayor número de defunciones fue el de 80-89. Se demostró relación entre sexo y grupo etario (p < 0,01). Las regiones con mayor tasa de mortalidad observada fueron Magallanes, Valparaíso y Maule. Discusión: La tasa de mortalidad es similar a la reportada a nivel mundial. Las mujeres mueren en una proporción mayor que los hombres, tal como es descrito en otros estudios. La mayor tasa de mortalidad observada en algunas regiones del país se podría asociar a la elevada prevalencia de factores de riesgo para la enfermedad. Conclusión: Las defunciones por enfermedad diverticular disminuyeron desde el año 2018, se evidencia que las mujeres presentan un número significativamente mayor de defunciones que los hombres y que existieron diferencias por región.

Aim: To describe deaths from diverticular bowel disease in the period 2016-2020 in Chile according to sex, age group and region. Material and Method: Descriptive study. 406 deaths due to diverticular disease were described according to sex, age group and region between the years 2016-2020, performing a statistical analysis with the IBM SPSS Statistics ® software that included a Binomial Test for analysis of deaths according to "sex" and the Kruskal Wallis Test for the study of significance between the variables "sex" and "age group". A 99% confidence interval (p < 0.01) was used. Results: A mortality rate of 0.46/100,000 inhabitants was obtained for the period. The female sex was predominant in a ratio close to 3:1 (p < 0.01). Deaths increased with age and the age group with the higher number of deaths was 80-89. A relationship between sex and age group was demonstrated (p < 0.01). The regions with the highest observed mortality rate were Magallanes, Valparaíso and Maule. Discussion: The mortality rate is similar to that reported worldwide. Women die at a higher rate than men, as described in other studies. The higher mortality rate observed in some regions of the country could be associated with the high prevalence of risk factors for the disease. Conclusion: Deaths from diverticular disease decreased since 2018, in conjunction with showing that women present a significantly higher number of deaths than men and that there were differences by region.

La enfermedad diverticular hoy: revisión de la evidencia / Diverticular disease today: evidence review

Resumen La enfermedad diverticular es muy prevalente con gran repercusión económica y médica. A pesar de las múltiples guías para protocolizar el diagnóstico y tratamiento no existe unanimidad en su manejo. Hemos realizado una revisión actualizada con el objetivo de analizar los nuevos estudios de esta enfermedad, para manejarla adecuadamente y realizar el tratamiento más adecuado en cada momento. La enfermedad diverticular tiene un componente hereditario (40%) y presenta una relación directa con la dieta pobre en fibra, la obesidad, el consumo de carne roja, la inactividad, el alcohol y los AINEs. Por su clínica inespecífica, es difícil realizar un diagnóstico diferencial. La ecografía y el TC abdominal son métodos apropiados para el diagnóstico y se recomienda una colonoscopia de manera precoz (4ᵃ-8ᵃ semana) tras el cuadro agudo. La clasificación más seguida es la de Hinchey. En el tratamiento médico de la diverticulosis sintomática no se ha demostrado evidencia clara de ningún medicamento. La diverticulitis aguda no complicada se puede manejar ambulatoriamente y no es necesario el uso de antibióticos en pacientes sin factores de riesgo. En la diverticulitis complicada se tiende a un manejo conservador, aunque en el Hinchey III y IV el tratamiento es quirúrgico, recomendando la resección de la zona afecta y si es posible anastomosis con o sin estoma de protección. No se recomienda el lavado y drenaje en el Hinchey III. Hay que consensuar tratamiento de forma individualizada ya que no se recomienda tratamiento quirúrgico por el número de recurrencias ni por edad del paciente.

The diverticular disease is a prevalent condition with a great economic and medical repercussion. Despite the multiple guidelines available to protocolize diagnosis and treatment, there is not unanimity in its management. We have carried out an updated review with the aim of analyzing new studies of the disease, to manage it properly and to carry out the most appropriate treatment at each time. Diverticular disease has an inherited component (40%) and it is directly related to low fiber diet, obesity, consumption of red meat, inactivity, alcohol and NSAIDs. Due to its nonspecific symptoms, it is difficult to make a differential diagnosis. Ultrasound and abdominal CT are appropriate methods for diagnosis and early colonoscopy is recommended (4th-8th week) after acute symptoms. The most followed classification is the Hinchey Score. There is no clear evidence of the superiority of any drug in the treatment of symptomatic diverticulosis. Acute uncomplicated diverticulitis can be managed on an outpatient and the use of antibiotics is not necessary in patients without risk factors. Conservative management tends to be used in complicated diverticulitis, although in Hinchey III and IV the treatment is surgical, recommending resection of the affected area and, if possible, anastomosis with or without a protective stoma. Washing and draining is not recommended in the Hinchey III. Treatment must be agreed on an individual basis since surgical treatment is not recommended due to the number of recurrences or the age of the patient.

A vesico-peritoneal fistula in a patient with history of diverticulitis-related colovesical fistula repair: a case report

A vesico-peritoneal fistula is an epithelialized communication between the peritoneal cavity and the urinary bladder. It is a rare entity scarcely reported in medical literature. High index of suspicion is needed for diagnosis and treatment. Here we expose the case of a vesico-peritoneal fistula presenting with chronic abdominal pain 4 years after sigmoidectomy. A 38-year-old male presented with lower quadrant abdominal pain. He had history of sigmoidectomy with colorectal anastomosis and bladder repair due to diverticular disease-related colovesical fistula 5 years prior to admission. Elevated serum creatinine levels and oliguria were documented. Intraperitoneal free fluid was found by computed tomography (CT) scan. Percutaneous drainage was performed, and laboratory test showed elevated peritoneal creatinine levels. CT-Cystography revealed a vesico-peritoneal fistula. Dissection of fistulous tract and primary closure of bladder defect was achieved. Vesico-peritoneal fistulas have been described as surgical procedure complications with a variable postoperative time of presentation. Low index of suspicion led to delayed diagnosis, finally suspected by intraperitoneal fluid analysis and confirmed by cystography. Intraperitoneal reabsorption of urine elevated serum creatinine levels mimicking renal failure. Management ranges from conservative to surgical procedures, in this case fistulous tract dissection and primary bladder closure was accomplished. Vesico-peritoneal fistulas are rarely reported. Common clinical findings include chronic abdominal pain and free intraperitoneal fluid. Misdiagnosis of acute renal failure is frequent due to elevated serum creatinine levels and oliguria.  Laparoscopic dissection of fistulous tract and primary closure of bladder defect is a safe option as treatment of this condition.

Fístula colovesical de origen diverticular. Resolución laparoscópica con nuevo recurso técnico / Diverticular colovesical fistulae. Laparoscopic tip

Introducción: La enfermedad diverticular de colon es una patología de alta prevalencia en nuestro medio. Su presentación inicial como fístulas no complicadas no es frecuente sin antecedentes de episodios de diverticulitis previa. Objetivos: Presentar detalles técnicos de la cirugía de resección y tratamiento laparoscópico de una fistula colovesical de origen diverticular. Materiales y métodos: Se presenta el caso de un paciente varón de 63 años con dolor en hipogastrio sin alteraciones evacuatorias ni cirugías previas. Sin antecedentes de diverticulitis. Se realizó ecografía abdominal y tomografía computada donde se constata aire en vejiga. El urocultivo es positivo para escherichia coli y el colon por enema detecta pequeño trayecto fistuloso entre colon sigmoides y vejiga. Se decide resección laparoscópica. Resultados: Se realizó una colectomía sigmoidea laparoscópica con identificación de trayecto fistuloso a la vejiga que se aisló y seccionó entre clips de polímero. Se completó con anastomosis primara colorrectal y sondaje vesical prolongado que se retiró a los 15 días. Los parámetros postoperatorios fueron favorables con egreso a las 72 hs. Conclusión: La fístula colovesical es una complicación de la enfermedad diverticular de colon aunque es rara su debut como forma de presentación sin episodios de diverticulitis previa. Se destaca su identificación como trayecto único y no hemos encontrado mención al respecto en la bibliografía. Su resolución de ligadura entre clips es una opción terapéutica efectiva y rápida para su resolución definitiva. El abordaje laparoscópico electivo es de elección y su tratamiento mediante el procedimiento propuesto resultó efectivo y seguro.

Background: Diverticular disease is a high prevalent colonic pathology. Initial presentation as complicated disease includes fistulas, perforation and bleeding. Objetive: To present technical surgical aspects of surgical treatment of laporoscopic resection of colovesical fistula after diverticular disease. Methods: A 63 years old patient presented with low abdominal pain and no transit symptoms. There was no previous surgery and diverticulitis episode. Abdominal ultrasound and CT scan showed air in the bladder. Urine culture was positive to Escherichia coli. Colonic barium x-rays showed a colovesical fistula. Laparoscopic resection was decided as treatment of choice. Results: Laparoscopic sigmoid colectomy, aisolation of fistula tract and posterior clips ligation and section. Primary mecanic anastomosis and 15 days vesical catheter completed the treatment. Postoperative evolution was satisfactory. Conclusions: Colovesical fistula is a frequent complication of complicated diverticular disease, however its debut without previous episodes is rare. The colonic fistula presented as unique tract is unfrequent. Resolution by polimer clips and section associated with colonic resection by laparoscopic is a good option to avoid bladder sutures. This procedure resulted safe and effective.

Clinical Presentation, Management and Outcome in Diverticular Colovesical Fistulas - Our Experience.

Colovesical fistula (CVF) is an abnormal communication between the urinary bladder and the large intestine, usually sigmoid colon. Diverticulitis is the most common cause of CVF in most of the western studies, accounting for approximately 70% of cases. Diverticular CVF is uncommon in Asia. This case series shares the experience of six cases of diverticular CVF in Indian population. METHODSMedical records of six patients with diverticular colovesical fistulas during the period January 2016 - August 2019 were reviewed with regard to symptoms, diagnostic investigations, and management. Various aspects of the disease were analysed to determine the common features of colovesical fistula in our population. RESULTSAll patients with diverticular colovesical fistula were presented with urinary symptoms and none were aware about their existing colonic diverticulosis. Five out of the six cases presented with pneumaturia. Contrast enhanced computed tomography (CECT) abdomen detected sigmoid diverticulosis with vesical fistula in all cases. The most common site of fistula found on cystoscopy was on the left superolateral wall of bladder. All cases were operated as a single stage procedure including fistula repair, colonic resection, omental interposition with no temporary colostomy which provided an excellent surgical cure. CONCLUSIONSColovesical fistula secondary to diverticular disease has shown a rising incidence and can be effectively managed by a multidisciplinary team. It requires prompt diagnosis, adequate preoperative evaluation, perioperative care including bowel preparation, nutritional supplementation, appropriate antibiotics, and meticulous surgical skills allowing an elective one-stage approach.

Laparotomía abreviada y terapia de presión negativa para el cierre temporal del abdomen como tratamiento de la peritonitis diverticular Hinchey III/IV / Abbreviated laparotomy and negative pressure therapy for temporary closure of the abdomen as treatment of diverticular peritonitis Hinchey III/IV

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)

Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)

Fístula sigmoido-cervical secundaria a una enfermedad diverticular complicada / Sigmoido-cervical fistula due to diverticular disease

Resumen Introducción: Las fístulas secundarias a una enfermedad diverticular complicada son una indicación formal de cirugía electiva en el 4 a 23% de los casos. Caso Clínico: Se presenta el caso de una mujer de 52 años con antecedentes de una histerectomía subtotal por miomatosis uterina que consulta por cuadro de dolor abdominal en hipogastrio acompañado de fiebre de 4 días de evolución. La tomografía computada (TC) de abdomen y pelvis describe una diverticulitis complicada con absceso peridiverticular. Tratada con antibióticos con buena respuesta clínica consulta a los 3 meses en nuestro servicio por pérdida de material fecal por vagina. Nueva TC confirma la presencia de una colección perisigmoidea y engrosamiento de la pared vesical. La colonoscopía informa una estenosis franqueable a nivel de sigmoides y se constata salida de gases por vagina. La corrección quirúrgica electiva incluyó una sigmoidectomía abierta con traquelectomía en block, cierre de la cúpula vaginal y anastomosis colorrectal mecánica, con buena evolución posoperatoria, sin recidiva a los 12 meses de seguimiento. La fístula sigmoido-cervical es una complicación rarísima de la enfermedad diverticular complicada que puede ocurrir en pacientes sometidas a una histerectomía subtotal previa. Aunque el diagnóstico de la fístula es clínico, la colonoscopía y la TC permiten descartar otras etiologías. La resección radical del segmento afectado es el tratamiento estándar en pacientes aptos.

Introduction: Diverticular disease is complicated by fistulas in 4% to 23% of patients. Case Report: A woman 52 years-old previously operated on with parcial histerectomy was successfully treated with antibiotics due to diverticulitis complicated with an abscess. Three months later the patient presented with vaginal discharge of faeces. Computed tomography showed wall thickening of sigmoid colon and vesical wall. Colonoscopy exclude cancer and confirmed the exit of gas through vagina. En-bloc resection of the sigmoid colon with traquelectomy with primary anastomosis was performed. The postoperative course was good without recurrence after 12 months of follow up. Sigmoido-cervical fistula is a very rare benign fistula due to diverticular disease. Diagnosis is basically clinic, but tomography and colonoscopy are important to exclude other causes of fistulas. Radical surgery with primary anastomosis is the standard treatment.

Enfermedad diverticular: nuevas perspectivas en el tratamiento dieto-terapéutico / Diverticular disease: new perspectives in diet-therapeutic treatment

La enfermedad diverticular corresponde a una condición habitual en el territorio occidental, siendo el hallazgo más frecuente en población de zonas urbanizadas. Respecto a su origen, se ha planteado la influencia de factores ambientales y genéticos, incluyendo en su etiología una inadecuada ingesta de fibra dietética, disbiosis de la microbiota intestinal y niveles alterados de vitamina D. A su vez, la enfermedad diverticular sintomática no complicada (EDNC) corresponde a un tipo de diverticulosis crónica cuyas características asemejan al síndrome de intestino irritable, lo que resalta la importancia en la comprensión de esta condición. Recientemente, se ha discutido la forma en que se aborda la enfermedad diverticular y en el siguiente escrito se expondrá evidencia sobre la patogénesis y su actual manejo.

Diverticular disease corresponds to a habitual condition in the western territory, being frequently found among the population of urban areas. Regarding its origin, the influence of environmental and genetic factors, including the etiology of dietary fiber intake, intestinal microbiota dysbiosis and altered levels of vitamin D have been recognized. Symptomatic uncomplicated diverticular disease corresponds to a type of chronic diverticulosis whose characteristics resemble irritable bowel syndrome, highlighting the importance of understanding this condition. Recently, the treatment of the disease has been discussed and the following review presents evidence on pathogenesis and its management.

Fístulas colónicas de origen diverticular / Colonic fistulas of diverticular origin

INTRODUCCIÓN: La enfermedad diverticular de colon sigmoides representa la principal causa de fistulización del colon a órganos vecinos. OBJETIVO: Describir variables clínicas y terapia quirúrgica de esta entidad. MATERIALES Y MÉTODO: Revisión retrospectiva de los casos de fístulas colónicas de origen diverticular (FCD) operados en forma electiva en un centro terciario. RESULTADOS: En un periodo de 30 años se realizó cirugía resectiva por una FCD en 49 pacientes. Los órganos más afectados fueron la vejiga en 33 casos (68%) y la vagina en 6 (12%). La cirugía efectuada fue la sigmoidectomía en 48 casos (5 con una ileostomía de protección) y una operación de Hartmann. La vía de abordaje fue laparoscópica en 4 pacientes y la morbilidad global de la serie fue 20%, sin mortalidad. Con un seguimiento promedio de 87 meses (extremos 16-178) no hubo casos de recidiva de la fístula. CONCLUSIONES: La FCD representa el 26% de los casos intervenidos por una enfermedad diverticular de colon sigmoides, lo que probablemente refleja un diagnóstico tardío. La fístula colovesical (FCV) es la fístula más común por esta causa y en la mitad de los casos tienen una presentación silenciosa. Las fístulas colovaginales ocurren en mujeres histerectomizadas. La cirugía resectiva del colon en pacientes con riesgo normal es la cirugía estándar con buenos resultados a corto y largo plazo. La cirugía laparoscópica es factible y segura especialmente en los casos de FCV.

BACKGROUND: Fistula formation is a well-known complication of diverticular disease (FCD). AIM: Determine the clinical presentation and surgical management of this kind of fistulas. MATERIALS AND METHODS: Retrospective revision of all consecutive scheduled cases operated on in a terciary public centre in a thirty-years period. RESULTS: Forty-nine patients with a segmental resection of sigmoid colon were analized. Colovesical fistulas were the most common type (n = 33), followed by colovaginal (n = 6). Resection with anastomosis was performed in 48 cases and Hartmann type operation in one. Laparoscopic procedure was made in 4 cases without conversion. Complication rate was 20% and two patients were reoperated on, without mortality in this series. Follow up showed no case of recurrence. CONCLUSIONS: FDC represent 26% of cases operated on in our series. Colovesical fistula is the most common type, followed by colovaginal fistula in histerectomized women. Resection and primary anastomosis should be the treatment of choice in average risk patients with acceptable morbidity and good long-term results. Laparoscopic approach is safe, specifically in patients with colovesical fistulas.

A double row epiploicoplasty for primary closure of free perforated sigmoid diverticulitis / Epiploicoplastia de duas fileiras para fechamento primário de diverticulite perfurada livre de sigmoide

ABSTRACT Acute free perforation of the sigmoid diverticulitis is an emergency surgical intervention required condition. Although the sigmoid resection and temporary end colostomy or abdominal lavage and drainage are the most commonly used surgical methods for its treatment, the most effective surgical method has not been established yet. We applied a different surgical method for the surgical treatment of free perforation of acute sigmoid diverticulitis outside of these surgical procedures. A double row epiploicoplasty was performed for surgical treatment of free perforated sigmoid diverticulitis with surgical success in a patient who had concominant serious diseases.

RESUMO A perfuração livre aguda da diverticulite de sigmoide é um problema que exige intervenção cirúrgica de emergência. Embora a ressecção de sigmoide e a colostomia de extremidade temporária ou a lavagem e drenagem abdominal sejam os métodos cirúrgicos mais comumente utilizados para o seu tratamento, o método cirúrgico mais eficaz ainda não foi estabelecido. Aplicamos um método cirúrgico diferente para o tratamento cirúrgico de perfuração livre de diverticulite de sigmoide aguda fora desses procedimentos cirúrgicos. Uma epiploicoplastia de duas fileiras foi realizada para o tratamento cirúrgico de diverticulite perfurada livre de sigmoide com sucesso cirúrgico em um paciente com doenças graves concomitantes.

Impact of CT imaging on predicting the surgical management of acute diverticulitis

PURPOSE: The incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment. METHODS: Three hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index. RESULTS: After propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively). CONCLUSION: This study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Diverticular Disease: An Update on Pathogenesis and Management

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Antibiotics versus no antibiotic therapy for uncomplicated sigmoid diverticulitis: A meta-analysis / The Health Sciences Journal

INTRODUCTION@#Antibiotics have been used customarily in the treatment of uncomplicated diverticulitis since their introduction and have become the standard of care. The aim of this study is to compare the effectiveness of antibiotic therapy versus no antibiotic therapy in the treatment of uncomplicated sigmoid diverticulitis.@*METHODS@#An electronic search for randomized controlled trials comparing antibiotics versus no antibiotic therapy for uncomplicated diverticulitis was conducted. The outcomes considered were associated morbidity (abscess formation and sigmoid perforation); need for sigmoid colon resection, and recurrence of diverticulitis. The included studies were evaluated for risk of bias. Meta-analysis with Forest plot was performed using Review Manager Version 5.3.@*RESULTS@#Two trials, consisting of 1,151 subjects, were included in the meta-analysis. There was no difference in the risk of sigmoid perforation (RR 1.02, 95% CI 0.30, 3.49). Abscess formation and incidence of sigmoid resection were lower in the antibiotics groups (RR 2.24, 95% CI 0.51, 9.95 and RR 1.59, 95% CI 0.75, 3.36, respectively) but the differences were not significant. There was no difference in the recurrence of diverticulitis (RR 1.05, 95% CI 0.74, 1.78) between the two groups.@*CONCLUSION@#There is no definite advantage in giving antibiotics to patients with uncomplicated diverticulitis. Not giving antibiotics may be an acceptable treatment option for patients with acute uncomplicated sigmoid diverticulitis.

Prevención de la Diverticulitis Aguda Recurrente on Bacillus clausii

La Enfermedad Diverticular (ED) o Diverticulosis, es una de las enfermedades gastrointestinales más comunes que afectan a la población general en el mundo occidental, un 20 % de los pacientes son sintomáticos y el 75 % de ellos tendrá ED dolorosa: diverticulitis aguda, 25-33 % de estos pacientes pueden tener episodios recurrentes.Cambios en la Microbiota del colon, ocasionando inflamación crónica y proliferación de células epiteliales que se desarrollan en la mucosa del colon en y alrededor de los divertículos. Los prebióticos, restauran el microambiente del colon y de aquí, que se han propuesto para el tratamiento de los pacientes con ED asintomática para evitar la Diverticulitis Aguda. Objetivo del estudio fue investigar la proporción de pacientes que mantuvieron la remisión después de un episodio previo de Diverticulitis Aguda no complicada, cuando recibieron como tratamiento Bacillus clausii: 2 billones cada 8 horas por 1 año. Materiales y métodos: Estudio prospectivo y retrospectivo, con un muestreo no probabilístico de tipo intencional, con grupo control. Grupo A: Los 50 pacientes con el diagnostico de Diverticulitis Aguda no complicada, recibieron como único tratamiento Bacillus clausii 2 billones cada 8 horas, permanente por 1 año. Controles clínicos cada 3 meses. Grupo B (control): 50 pacientes conel diagnostico de Diverticulitis Aguda no complicada no tratados.Resultados:Se introdujo la información necesaria para realizar los análisis de varianza en R, encontrándose diferencia significativa entre las medias de los grupos considerados en el estudio, al obtenerse un F(1,48)=5.259, p <0.05.Conclusión: El Bacillus clausii por su características biológicas previene las complicaciones inflamatorias de la Enfermedad Diverticular como es la Diverticulitis Aguda Recurrente.

Diverticular Disease (DD), or Diverticulitis, is one of the most common gastrointestinal diseases affecting the general population in the western world; approximately 20% of patients are symptomatic and 75% suffer from painful DD: acute diverticulitis, 25-33% of those patients may suffer from recurrent episodes. Changes in colon microbiota cause chronic inflammation and epithelial cell proliferation developed in colon mucosa and around the diverticula. Prebiotics restore colon’s microenvironment, from where the treatment of patients with asymptomatic DD is proposed, in order to avoid the Acute Diverticulitis. The study aimed to investigate the proportion of patients who maintained the referral after a previous episode of uncomplicated Acute Diverticulitis, when treated with Bacillus clausii: two billions every eight hour during one year. Materials and Methods: Prospective and retrospective study, with non-probabilistic, intentional-type sampling and control arm. Arm A: Fifty patients diagnosed with uncomplicated Acute Diverticulitis, were administered with a single treatment of Bacillus clausii, two billions, every eight hours during one year. Clinical controls every three months. Arm B (control): 50 untreated patients diagnosed with uncomplicated Acute Diverticulitis. Outcomes: The necessary information to carry out the R variance analysis was introduced; a significant difference was found between the study’s arm averages; a F(1,48)=5.259, p<0.05 was found. Conclusion: because of its biological characteristics, Bacillus clausii prevents Diverticular Disease’s inflammatory complications such as the Recurrent Acute Diverticulitis.

Enfrentamiento actual de la enfermedad diverticular complicada. visión del gastroenterólogo / Current approach to complicated diverticular disease by the gastroenterologist

Prevalence of colonic diverticulosis is increasing, although usually asymptomatic. Acute diverticulitis (AD)is the most frequent complications, afflicting 1-2 percent of cases in the long term. Diagnosis and classification of AD can usually be accomplished by simple clinical manifestations and laboratory tests. Ultrasonography and CT scan are the most frequently used imaging tests to confirm diagnosis and detect complications. Modifications to the classical Hinchey classification have incorporated uncomplicated AD (without abscess or perforation), the most frequent presentation, allowing to suggest therapy according to the severity of the disease. Uncomplicated AD usually has a benign course, does not require hospitalization and there is growing evidence suggesting that antibiotics are not required. Recurrence is uncommon and with low risk. The number of recurrences by itself is no more a valid criterion to indicate surgery and most patients should be managed medically, although there are no drugs with proven utility to modify the risk of recurrence. Complicated AD can be managed with intravenous antibiotics and percutaneous drainage of abscesses. Surgery is indicated in case of free perforation or diffuse peritonitis. There is a growing trend to use laparoscopic approach and perform peritoneal lavage, without resection in the emergency setting. However, many patients will require resective surgery during the follow-up. The classical paradigms that have guided the approach to colonic diverticulosis are being challenged by the lack of evidence, but the new ones still have to be constructed. For now, we must tolerate high levels of uncertainty and heterogeneity in the management of this common condition.

La diverticulosis colónica ha aumentado su frecuencia, es generalmente asintomática y se complica entre 1-2 por ciento a largo plazo, siendo la diverticulitis aguda (DA) la complicación más frecuente. El diagnóstico y categorización de la DA puede realizarse en base a las manifestaciones clínicas y exámenes de laboratorio simple. Las imágenes más utilizadas son la ecotomografía y la tomografía computada. Se han sugerido modificaciones a la clásica clasificación de Hinchey, que incorporan la DA no complicada y permiten sugerir la terapia de acuerdo a la gravedad. La DA no complicada (sin absceso ni perforación) es la presentación clínica más frecuente. Su evolución es benigna, no requiere hospitalización y existe evidencia creciente que cuestiona la utilidad de los antibióticos. La recurrencia es infrecuente y de bajo riesgo. El número de recurrencias no es un criterio válido para indicar la cirugía. La DA complicada puede manejarse con antibióticos intravenosos y drenaje percutáneo de abscesos. La cirugía está indicada en caso de perforación libre o peritonitis difusa. Existe una tendencia creciente a realizar aseo por vía laparoscópica, sin resección. La mayor parte de los pacientes con DA complicada requieren cirugía resectiva durante la evolución, mientras que aquellos con DA no complicada son de manejo médico, aunque no existen fármacos con utilidad demostrada para modificar el riesgo de recurrencia. Los paradigmas que han guiado el enfrentamiento de la diverticulosis colónica están siendo cuestionados por la falta de evidencia, por lo que, por ahora, debemos tolerar altos niveles de incerteza y heterogeneidad en el manejo de esta frecuente patología.

Colonic Perforations Caused by Migrated Plastic Biliary Stents

No abstract available.

Hemorragia digestiva baixa maciça por doença diverticular em jejuno / Lower massive bleeding due to jejunum diverticulosis

A doença diverticular do trato gastrointestinal é uma entidade que ocorre mais requentemente no cólon. No intestino delgado, a prevalência é de 0,3-1,9%, com 60-70% ocorrendo no duodeno, 20-25% no jejuno e 5-10% no íleo. Localiza-se na borda mesentérica e resulta da combinação da discinesia intestinal com o aumento da pressão intraluminal, acometendo preferencialmente idosos e o sexo masculino. É geralmente assintomática e suas complicações, como volvo, obstrução intestinal, diverticulite, perfuração, abscesso e hemorragia digestiva são raras. Na hemorragia digestiva baixa (HDB) maciça, a história clínica e o exame físico são pouco úteis e, embora extremamente rara, têm alta taxa de mortalidade. Os exames disponíveis para diagnóstico incluem colonoscopia, angiografia mesentérica, cintilografia com hemácias marcadas Tc 99, endoscopia por duplo balão e cápsula endoscópica. Pacientes hemodinamicamente instáveis devem ser submetidos à laparotomia com ressecção do segmento ? contendo os divertículos ? com anastomose primária. Relatamos um caso de HDB maciça em paciente idosa, acometida por neoplasia metastática de origem desconhecida e em uso crônico de anticoagulante oral. Apesar de a paciente ter recebido manejo considerado apropriado, com acesso aos exames adequados, tratamento cirúrgico de escolha e sem evidências de ressangramento após o ato operatório, seu desfecho foi negativo.

The diverticular disease of the gastrointestinal tract is an entity that occurs more frequently in the Cólon. In the small bowel the prevalence is 0.3 to 1.9%, with 60-70% occurring in the duodenum, 20-25% in the jejunum and 5-10% in the ileum. It is located in the mesenteric border and results from the combination of intestinal dyskinesia with high intraluminal pressure. It also affects mainly elderly and male gender. It is usually asymptomatic and its complications such as volvulus, intestinal obstruction, diverticulitis, perforation, abscess and gastrointestinal bleeding are rare. The massive lower gastrointestinal bleeding, although extremely rare, has a high mortality rate. History and physical examination are of little use. The tests available for diagnosis include colonoscopy, mesenteric angiography, Tc-99m cintigraphy, double balloon endoscopy and capsule endoscopy. Hemodynamically unstable patients should undergo laparotomy and the resection of the segment with primary nastomosis is the procedure of choice. We report a case of massive lower gastrointestinal bleeding in elderly patient, affected by severe comorbidity ? metastatic neoplasia - and concomitant use of oral anticoagulants. Although the patient had received management considered appropriate, with access to the right imaging exams, treatment of choice and no evidence of bleeding after surgery, her outcome was negative.

Fístula colovesical secundaria a enfermedad diverticular: cirugía laparoscópica electiva / Colovesical fistula: laparoscopic surgery

Aim: Colovesical fistula is a severe complication associated to neoplastic or inflammatory colon disease. Most common procedure is open surgery. We report a case of colovesical fistula secondary to diverticular disease treated with a laparoscopic approach. Methods: A 64-year-old man was seen with a known colonic diverticular disease, type 2 diabetes mellitus and recurrent urinary tract infection. He complained of lower abdominal pain, dysuria, and pneumaturia. A CT scan revealed a sigmoid diverticular perforation into the bladder (colovesical fistula). A left hemicolectomy with partial cystectomy was performed by laparoscopy means. Results: There was no morbidity related to the surgical procedure, and the final pathology confirmed a colonic diverticular disease with bladder compromise. The patient is asymptomatic at 24 months of follow up. Conclusion: The laparoscopic approach is a feasible alternative for the treatment of colovesical fistula with low morbidity.

Objetivos: La fístula colovesical es una complicación relacionada con procesos inflamatorios y neoplá-sicos del colon. El manejo tradicional de esta patología es quirúrgico bajo técnica abierta. Presentamos un caso de fístula colovesical secundaria a enfermedad diverticular con tratamiento quirúrgico laparoscópico. Materiales y Métodos: Paciente masculino de 64 años de edad, portador de enfermedad diverticular de larga data con antecedente de diabetes mellitus tipo 2 e infecciones urinarias a repetición, quien consulta por presentar dolor en hipogastrio, disuria y neumaturia. Se realiza tomografía computada que revela perforación diverticular de colon sigmoides a vejiga (fístula colovesical). Se realizó hemicolectomía izquierda más cistectomía parcial, con resección del trayecto fistuloso, y cierre vesical y anastomosis colónica laparoscópica. Resultados: No hubo complicaciones intra ni postoperatorias. El estudio anatomopatológico de la pieza operatoria demostró enfermedad diverticular. El paciente se encuentra asintomático a los 24 meses de seguimiento. Conclusión: El abordaje laparoscópico es una alternativa factible para el tratamiento de fístula colovesical, con baja morbilidad.

Colectomía parcial laparoscópica electiva por enfermedad diverticular / Elective laparoscopic colectomy for diverticular disease

Background: Colorectal colectomy is a less invasive technique that can be used for the treatment of diverticular disease, recently in younger patients. Aim: To report the experience with laparoscopic colectomy for diverticular disease. Material and Methods: All patients with indication for elective surgical resolution for diverticular disease were subjected to laparoscopic surgery from 1997 to 2009. The surgical protocols of these patients were analyzed. Results: Sixty patients with average age 53,8 (31 males) were operated in the period. Forty six were subjected to a sigmoidectomy and 14 to left hemicolectomy. Operative average time was 173 minutes and hospital stay 4,16 days. Three patients had to be converted to open surgery and three had complications that were managed without need of reoperation. During a median follow up of 38 months, the disease relapsed in two patients, which did not require a new intervention. Conclusions: Elective laparoscopic colectomy for diverticular disease is feasible and safe.

La cirugía laparoscópica colorrectal, aunque de desarrollo lento, ha presentado en los últimos años ventajas con respecto a la cirugía abierta. Hay escasas publicaciones nacionales sobre esta técnica en enfermedad diverticular. Objetivo: Presentar nuestra experiencia en enfermedad diverticular en una serie consecutiva de pacientes con indicación quirúrgica electiva resueltos por vía laparoscópica. Material y Método: Se analizan los protocolos prospectivos de cirugía laparoscópica de colon con diagnóstico de enfermedad diverticular para resolución electiva, desde junio de 1997, hasta diciembre de 2009. Todo paciente con indicación quirúrgica electiva por esta patología fue resuelto por vía laparoscópica. Se estudian edad, sexo, tipo de resección, evolución postoperatoria inmediata y tardía. Resultados: Se operaron 60 pacientes, con edad promedio de 53,8 años. De éstos 46 fueron sigmoidectomías y 14 hemicolectomías izquierdas. El tiempo operatorio promedio fue de 173 minutos y la hospitalización de 4,16 días. Se convirtieron 3 pacientes (5 por ciento) y hubo 3 complicaciones (5 por ciento), que fueron manejadas médicamente. Hubo 1 estenosis de anastomosis tratada endoscópicamente como complicación tardía. Seguimiento promedio de 37,9 meses. Hubo 2 recidivas (3,3 por ciento), tratadas médicamente y no hubo mortalidad en esta serie. Conclusión: La cirugía laparoscópica para la enfermedad diverticular electiva es factible de realizar en la gran mayoría de los pacientes, con baja morbilidad y rápida recuperación.

Divertículo gigante do cólon: uma doença rara com localização atípica / Giant colonic diverticulum, a rare disease with atypical localization

O divertículo gigante do cólon é uma rara patologia com menos de 150 casos descritos na literatura inglesa, sendo a primeira referência feita pelos franceses Bonvin e Bonte em 1946. Em 90% dos casos, esta patologia localiza-se no cólon sigmoide e a sua apresentação pode variar desde a forma assintomática até o abdômen agudo. O caso descrito ocorreu em um paciente masculino, com 55 anos, e apresentou-se insidiosamente, com quadro clínico infeccioso e diagnóstico realizado por ressonância nuclear magnética e enema opaco. A localização do divertículo é atípica no cólon transverso, e o tratamento realizado foi cirúrgico com diverticulectomia, apresentando pós-operatório sem complicações.

Giant colonic diverticulum is a rare disease with fewer than 150 cases reported in English literature, the first reference made by the French Bonvin and Bonte in 1946. In 90% of cases the pathology is located in the sigmoid colon and the presentation of this disease can vary from asymptomatic to the acute abdomen. The case described occurred in a male patient aged 55 years and presented insidiously with clinical infection and diagnosis by MRI and barium enema. The location of divertículo is atypical in the transverse colon, and the patient was treated with surgical diverticulectomy, with no postoperative complications.