Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65–74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65–92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1–48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

EP.FRI.1040 Management of Acute Colonic Diverticulitis According to The WSES (World Society of Emergency Surgery) Classification in a Tertiary Centre

Aims Debate remains regarding management of complicated diverticulitis. The WSES acute diverticulitis working group published in 2015 a CT-guided classification of left colon acute diverticulitis, divided into uncomplicated (Stage 0) and complicated (Stage 1a-4). Using this classification, we reviewed our management of CT-proven acute colonic diverticulitis. Methods A single-centre retrospective review of management of CT-proven acute colonic diverticulitis over 12 months based on the WSES classification. Results 24 males and 31 females presented (median age=56, IQR 45-68). Median white cell count=12 (IQR 10-16) and median C-reactive protein=88 (IQR 41-157). Based on CT, 25 (45.5%) patients =stage 0, 14 (25.5%) =stage 1a, 6 (11%) =stage 1b, 4 (7%) =stage 2a, 6 (11%) =stage 2b, and none staged 3/4. 15% (8/55) patients had an operation, remainder were conservatively managed. 2 patients had laparoscopic washout/drainage (stages 1b and 2b). 6 patients had Hartmanns (x1 stage 1a, x1 stage 1b, x4 stage 2b). Median length of stay=5 days (IQR 4-8). There was 1 related reattendance declining readmission (stage 1a managed conservatively) and 2 readmissions (1 stage 0 managed conservatively, other initially stage 1a managed conservatively but on readmission staged 2b proceeding to Hartmanns). 30-day mortality included 3 deaths (stages 1b/2a/2b all managed conservatively). Conclusions Hartmanns resection is advocated as treatment of choice for complicated acute diverticulitis, particularly for Stage 2b or above.

SP1.1.16Endoscopic evaluation after acute colonic diverticulitis: Review of literature

Aim To compare the current evidence for routine endoscopic evaluation of the colon after an episode of acute diverticulitis against existing guidelines in the United Kingdom. Methodology A systematic literature search of Medline, Embase and Cochrane databases was performed using keywords “Diverticular disease”, “Diverticulitis”, “acute”, “Colorectal Cancer” and “endoscopy”. Recommendations from guidelines of specialist medical societies were reviewed. Available literature was explored to assess the risk of colorectal cancer in patients presenting with acute diverticulitis. Results The most recent UK guideline (Royal College of Surgeons Commissioning guide 2014 supported by ACPGBI) recommends the routine evaluation of colonic lumen after resolution of an acute attack of diverticulitis. More recent guidelines from specialist medical societies (European Society of Coloproctology 2020, World Society of Emergency Surgery 2020, European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons 2018) do not recommend routine endoscopic evaluation after recovery from uncomplicated colonic diverticulitis. Two meta-analyses as well as three large cohort studies showed no significant risk of colorectal cancer ((1.22% (95% confidence interval 0.63-1.97) and (0.7%; confidence interval 0.3%−1.4%)) following uncomplicated acute diverticulitis. Conclusion Existing UK guidance on routine colonic luminal evaluation after resolution of acute diverticulitis should be revised based on current evidence.

EP.FRI.12Meta-analysis of demographic and prognostic significance of right-sided versus left-sided acute diverticulitis

Aims To compare the demographic and prognostic outcomes of right-sided versus left-sided acute colonic diverticulitis Methods We performed a systematic review in accordance with the PRISMA statement standards to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis. We used the ROBINS-I tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients (MD:-14.16,P&lt;0.00001) and more male patients (OR:1.33,P=0.02) compared with left-sided diverticulitis. Smoking (OR:2.23,P&lt;0.0001), alcohol consumption (OR:1.85,P=0.002) and co-morbidity (OR:0.21,P&lt;0.00001) were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group (OR:0.21,P=0.001). More patients in the right-sided diverticulitis group had modified Hinchey stage I disease (OR:10.21,P&lt;0.0001) while more patients in the left-sided group had stage II (OR:0.19,P&lt;0.00001), stage III (OR:0.08,P=0.009) or stage IV disease (OR:0.02,P&lt;0.00001). Right-sided diverticulitis was associated with a lower risk of recurrence (OR:0.49,P=0.04), failure of conservative management (OR:0.14,P=0.0006), the need for emergency surgery (OR:0.13,&lt;0.00001) and shorter length of hospital stay (MD:-1.70,P=0.02). Conclusions Right-sided acute colonic diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence, and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Routine antibiotics may not be needed to treat uncomplicated right diverticulitis: A retrospective cohort study

We aimed to investigate whether antibiotic administration is necessary for patients with uncomplicated right colonic diverticulitis. Data from patients diagnosed with uncomplicated right colonic diverticulitis, who received inpatient treatment at a single center between January 2019 and January 2021, were retrospectively examined. The patients were divided into two groups according to whether antibiotics were administered. The patients were matched between groups using propensity score matching in a 1:1 ratio using logistic regression with the nearest-neighbor method. The primary study outcome was the length of hospital stay, and the secondary outcomes were time to the introduction of sips of water and a soft diet. The study included 138 patients who received antibiotics and 59 who did not. After propensity score matching, 55 patients were assigned to each treatment group. There was no significant difference between the two groups in terms of age (p = 0.772), sex (p>0.999), body mass index (p = 0.121), prehospital symptom duration (p = 0.727), initial body temperature (p = 0.661), white blood cell count (p = 0.688), or C-reactive protein level (p = 0.337). There was also no statistically significant difference in the length of hospital stay between the no antibiotic and antibiotic groups (3.1±0.7 days vs. 3.0±1.0 days, p = 0.584). Additionally, no significant difference was observed between the no antibiotic and antibiotic groups with respect to time to sips of water (2.1±0.7 days vs. 1.8±0.9 days, p = 0.100) and time to the introduction of a soft diet (2.4±0.8 days vs. 2.1±0.9 days, p = 0.125). The findings suggest that routine antibiotics may be not required for treating patients with uncomplicated right colonic diverticulitis.