Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis.

BACKGROUND: Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous drainage followed by delayed resection. Controversy has arisen regarding the necessity of elective surgery, when nonoperative management has successfully resolved the index attack. OBJECTIVE: The aim of this systematic review was to analyze the literature to determine the recurrence rate in those patients who were successfully managed nonoperatively and determine the role of elective surgical resection. DATA SOURCES: An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews performed from 1986 to 2014. The search terms used were as follows: "diverticulitis," "abscess," "diverticular abscess," "percutaneous drainage," and "surgery." STUDY SELECTION: Studies included for review evaluated the management of diverticular abscesses and the subsequent role of delayed elective resection. INTERVENTIONS: All of the studies were systematically reviewed and underwent a meta-analysis. MAIN OUTCOME MEASURES: End points were the need for surgery and recurrent attacks without surgery. RESULTS: Twenty-two studies reporting a total of 1051 patients with acute diverticulitis with abscess formation (modified Hinchey grades IB and II) were included in the review. Percutaneous drainage was successful in 49% patients (diameter, >3 cm) and antibiotic therapy in 14% patients. Urgent surgery during the index hospitalization was performed in 30% of patients, elective resection in 36%, and no surgery in 35%. Recurrence rates were high, with 39% in patients awaiting elective resection and 18% in the nonsurgery group, with an overall recurrence rate of 28%. Of the whole cohort, only 28% had no surgery and no recurrence during follow-up. LIMITATIONS: Sample size, heterogeneity, selection and treatment bias, and limited follow-up of included studies were limitations to this study. CONCLUSIONS: The evidence from the literature is weak but still suggests that complicated diverticulitis with abscess formation is associated with a high probability of resective surgery, whereas conservative management may result in chronic or recurrent diverticular symptoms.

Patients' perspectives on fecal incontinence after brachytherapy for localized prostate cancer.

BACKGROUND: When a patient is deciding between treatment options for localized prostate cancer, brachytherapy is commonly chosen for its perceived low complication profile. Brachytherapy can frequently be complicated by the development of fecal incontinence. The potential long-term impact of this dysfunction on a patient's life should be discussed. OBJECTIVE: This study aimed to assess the long-term impact of brachytherapy for localized prostate cancer on fecal incontinence and to determine the impact and severity of the incontinence on patients' ability to engage in activities of daily living. DESIGN: A retrospective observational study was performed. A questionnaire packet was mailed to patients who had received brachytherapy treatment for localized prostate cancer and were now more than 2 years out from initial seed implantation. Each packet contained the Colon and Ano-Rectal Impact Questionnaire (assessing quality of life), the Colon and Ano-Rectal Distress Inventory, and the Cleveland Clinic Fecal Incontinence Score (both measured existence and severity of fecal incontinence). SETTINGS: This study was conducted at Caritas Christi St. Elizabeth's Medical Center, a tertiary referral center in Boston, Massachusetts from January 1, 1998 to December 31, 2007. PATIENTS: One hundred forty-three of 568 patients (a 25% response rate) responded and were analyzed. INTERVENTIONS: No interventions were performed. MAIN OUTCOME MEASURES: The main outcome was impact of fecal incontinence on quality of life. RESULTS: : Of the responses to the Colon and Ano-Rectal Impact Questionnaire, 13.2% (19 patients) (P < .001) stated that fecal incontinence was impacting their ability to participate in their daily activities. Sixty-three percent (12 patients) (P < .001) of patients described the impact of the incontinence as slight, 21% (4 patients) (P < .001) described it as moderate, and 15.8% (3 patients) (P < .001) described it as severe. LIMITATIONS: There were no case-matched controls and the response rate to the surveys was low. CONCLUSIONS: Postbrachytherapy fecal incontinence leaves a long-term impact on patients' ability to engage in activities of daily living.