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.

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.

Comparison of colonoscopy after colonic diverticulitis and positive fecal immunochemical tests for the detection of colorectal neoplasia

Background and study aims The relationship between acute colonic diverticulitis and colorectal cancer (CRC) is unclear, but colonoscopy is recommended to exclude malignancy. We compared the detection rates for colorectal neoplasia in patients with colonic diverticulitis and asymptomatic patients who had positive fecal immunochemical tests (FITs). Patients and methods In total, 282 patients with acute colonic diverticulitis were hospitalized in our hospital from February 2011 to December 2019. Of them, 143 patients with diverticulitis and 1819 with positive FITs patients during the same period underwent colonoscopy without a prior colonoscopy within 5 years. We retrospectively compared these patients in terms of the invasive CRC rate, advanced neoplasia detection rate (ANDR), adenoma detection rate (ADR), and polyp detection rate (PDR). Results Compared to the diverticulitis group, the FIT-positive group had a significantly higher CRC rate (0 vs 2.7 %, P = 0.0061), ANDR (5.6 vs. 14.0 %, P = 0.0017), ADR (19.6 vs. 53.2 %, P < .0001), and PDR (44.1 vs. 91.0 %, P < .0001). Using 1:1 propensity score matching based on age and sex, we obtained 276 matched patients in both groups. After matching, no difference was found in the CRC rate (0 vs 0.7 %) or ANDR (5.8 vs 7.3 %) between groups, but the ADR and PDR were significantly higher in the FIT-positive group (20.3 vs 43.5 %, P < .0001; 45.7 % vs 86.2 %, P < .0001). Conclusion Patients with acute diverticulitis had lower ADRs and PDRs than patients with positive FITs.