Surgical and non-operative treatment of acute complicated diverticulitis in a COVID hospital

Surgical treatment of acute abdomen during the SARS-CoV-2 pandemic was accompanied by an extremely high mortality rate, however, only a few studies have presented the results of acute inflammatory complications of diverticular disease (AICDD).
AIM: analysis of treatment of AICDD in a COVID-19 hospital.
PATIENTS AND METHODS: the retrospective study included 78 patients with acute diverticulitis (AD) from a COVID hospital, confirmed by CT or intraoperative revision. Assessment of COVID pneumonia, comorbidities, organ dysfunction, CT findings, peritonitis, treatment methods, and in-hospital mortality among patients was performed.
RESULTS: organ dysfunction of ≥ 1 point on the qSOFA scale was detected in 59.0% of the patients. According to CT data, abdominal distant gas was detected in 48 (61.5%) patients, and pericolic gas in 14 (17.9%) patients. Segmental colon resection was performed in 60 (76.9%) patients, laparoscopic lavage (LL) of the abdominal cavity — in 3, non-operative treatment (NOT) with drainage of fluid collections — in 6, and only NOT in 10 patients. Most patients with distant or pericolic gas were operated on within an average time of 1 [0; 3.5] hours after admission. Diffuse peritonitis was detected during surgery in 45 (75%) of them. After resection, organ dysfunction of ≥ 2 points on the SOFA scale developed or progressed in 52 (86.7%) patients. The overall mortality rate was 48.7%, and the postoperative mortality was 63.3%. All patients (n = 38) died after segmental colon resection. Successful NOT was achieved in 4 patients with pericolic gas and 3 patients with distant gas.
CONCLUSION: surgery for AICDD in patients with COVID-19 is associated with extremely high mortality, therefore, in the absence of obvious signs of diffuse peritonitis, initial non-operative treatment may be life-saving.

1. Lamm R, Mathews SN, Yang J, et al. 20-Year Trends in the Management of Diverticulitis Across New York State: an Analysis of 265,724 Patients. Journal of Gastrointestinal Surgery. 2016;21(1):78–84. doi: 10.1007/s11605-016-3205-0

2. Francis NK, Sylla P, Abou-Khalil M, et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidencebased recommendations for clinical practice. Surgical Endoscopy. 2019;33(9):2726–2741. doi: 10.1007/s00464-019-06882-z

3. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Advances in Surgery. 1978;12:85–109. PMID: 735943. Ссылка активна на 03.02.24. https://europepmc.org/article/med/735943

4. Sartelli M, Weber DG, Kluger Y, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World Journal of Emergency Surgery. 2020;15(1):32. doi: 10.1186/s13017-020-00313-4

5. Andeweg CS, Wegdam JA, Groenewoud J, et al. Toward an evidencebased step-up approach in diagnosing diverticulitis. Scandinavian Journal of Gastroenterology. 2014;49(7):775–784. doi: 10.3109/00365521.2014.908475

6. Schaffzin DM, Wong WD. Nonoperative Management of Complicated Diverticular Disease. Clinics in Colon and Rectal Surgery. 2004;17(3):169–176. doi: 10.1055/s-2004-832698

7. Mali J, Mentula P, Leppäniemi A, et al. Determinants of treatment and outcomes of diverticular abscesses. World Journal of Emergency Surgery. 2019;14(1):31. doi: 10.1186/s13017-019-0250-5

8. Ezerra RP, Costa AC da, Santa-Cruz F, et al. Hartmann procedure or resection with primary anastomosis for treatment of perforated diverticulitis? Systematic review and meta-analysis. ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 2020;33(3). doi: 10.1590/0102-672020200003e1546

9. Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019;156(5):1282–1298.e1. doi: 10.1053/j.gastro.2018.12.033

10. Azhar N, Johanssen A, Sundström T, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis. JAMA Surgery. 2021;156(2):121–127. doi: 10.1001/jamasurg.2020.5618

11. Nascimbeni R, Amato A, Cirocchi R, et al. Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper. Techniques in Coloproctology. 2020;25(2):153–165. doi: 10.1007/s10151-020-02346-y

12. Vermeulen J, Akkersdijk GP, Gosselink MP, et al. Outcome after Emergency Surgery for Acute Perforated Diverticulitis in 200 Cases. Digestive Surgery. 2007;24(5):361–366. doi: 10.1159/000107719

13. Vermeulen J, Gosselink MP, Hop WCJ, et al. Long-term survival after perforated diverticulitis. Colorectal Disease. 2011;13(2):203–209. doi: 10.1111/j.1463-1318.2009.02112.x

14. Gregersen R, Mortensen LQ, Burcharth J, et al. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. International Journal of Surgery. 2016;35:201–208. doi: 10.1016/j.ijsu.2016.10.006

15. Tebala GD, Milani MS, Bignell M, et al. Emergency surgery admissions and the COVID-19 pandemic: did the first wave really change our practice? Results of an ACOI/WSES international retrospective cohort audit on 6263 patients. World Journal of Emergency Surgery. 2022;17(1):6. doi: 10.1186/s13017-022-00407-1

16. Wang KY, McNeely EL, Dhanjani SA, et al. COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients. Spine. 2021;46(22):1551–1556. doi: 10.1097/brs.0000000000004204

17. Shao CC, McLeod MC, Thogaripally S, et al. Increased Risk of Postoperative Mortality Associated With Prior COVID-19 Infection. American Journal of Preventive Medicine. 2022;63(1):75–82. doi: 10.1016/j.amepre.2022.01.035

18. Cirocchi R, Nascimbeni R, Burini G, et al. The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review. Medicina. 2021;57(10):1127. doi: 10.3390/medicina57101127

19. Karpukhin O.Yu., Pankratova Yu.S., Shakirov R.R., et al. The influence of the COVID-19 pandemic on the diverticular disease complications treatment. Vestnik sovremennoi klinicheskoi meditsiny. 2022;15(3):33–39. (In Russ.). doi: 10.20969/VSKM.2022.15(3).33–39

20. Aulet TH, Spencer SB, Abelson JS, et al. Impact of the first COVID-19 surge on the outcomes of diverticulitis. Surgery in Practice and Science. 2022;10:100116. doi: 10.1016/j.sipas.2022.100116

21. Sallinen VJ, Mentula PJ, Leppäniemi AK. Nonoperative Management of Perforated Diverticulitis With Extraluminal Air Is Safe and Effective in Selected Patients. Diseases of the Colon&Rectum. 2014;57(7):875–881. doi: 10.1097/dcr.0000000000000083

22. Sallinen VJ, Leppäniemi AK, Mentula PJ. Staging of acute diverticulitis based on clinical, radiologic, and physiologic parameters. Journal of Trauma and Acute Care Surgery. 2015;78(3):543–551. doi: 10.1097/TA.0000000000000540

23. Yakovlev S.V., Brikko N.I., Sidorenko S.V., et al. SCAT Program (Strategy for the Control of Antimicrobial Therapy) in the Provision of Inpatient Care: Russian Clinical Guidelines. Moscow: Pero Publishing; 2018:156. (In Russ.). Link active as of 04.02.24 https://nasci.ru/?id=2880

24. Avdeev A.M., Abdulaev M.A., Afaq M.T., et al. The introduction of laparoscopy into practice with subsequent delayed operational treatment in complicated diverticular disease of the colon. Vestnik SPBGU. Meditsina. 2017;12(4):354–364. (In Russ.). doi: 10.21638/11701/spbu11.2017.405

25. Soliman SS, Rolandelli RH, Chang GC, et al. How the COVID-19 pandemic affected the severity and clinical presentation of diverticulitis. Intestinal Research. 2023;21(4):493–499. doi: 10.5217/ir.2022.00042

26. Uttinger KL, Brunotte M, Diers J, et al. Diverticulitis patient care during the Covid-19 pandemic in Germany—a retrospective nationwide population-based cohort study. Langenbeck. 2023;408(1):447. doi: 10.1007/s00423-023-03184-w

27. COVID Surg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARSCoV-2 infection: an international cohort study. The Lancet. 2020;396(10243):27–38. doi: 10.1016/s0140-6736(20)31182-x

28. Hossain N, Naidu V, Hosny S, et al. Hospital Presentations of Acute Diverticulitis During COVID-19 Pandemic may be More Likely to Require Surgery due to Increased Severity: A SingleCentre Experience. The American Surgeon. 2020;88(1):133–139. doi: 10.1177/0003134820982560

29. Sirinthornpunya S. Characteristics and Treatment Outcomes of Colonic Diverticulitis in Hospitalized Patients in Thailand. J Med Assoc Thai. 2016;99:136. PMID: 27266228.

30. Ince M, Stocchi L, Khomvilai S, et al. Morbidity and mortality of the Hartmann procedure for diverticular disease over 18years in a single institution. Colorectal Disease. 2012;14(8):492–498. doi: 10.1111/j.1463-1318.2012.03004.x

31. Li D, Baxter NN, McLeod RS, et al. Evolving Practice Patterns in the Management of Acute Colonic Diverticulitis. Diseases of the Colon & Rectum. 2014;57(12):1397–1405. doi: 10.1097/dcr.0000000000000224

32. McDermott FD, Collins D, Heeney A, et al. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. British Journal of Surgery. 2013;101(1):90–99. doi: 10.1002/bjs.9359

33. Martín-Román L, Fernández-Martínez M, Kayser Mata S, et al. Relevance of pneumoperitoneum in the conservative approach to complicated acute diverticulitis. A retrospective study identifying risk factors associated with treatment failure. Minerva Surgery. 2022;77(4):327–334. doi: 10.23736/s2724-5691.21.08997-8

34. Karentzos A, Ntourakis D, Tsilidis K, et al. Hinchey Ia acute diverticulitis with isolated pericolic air on CT imaging; to operate or not? A systematic review. International Journal of Surgery. 2021;85:1–9. doi: 10.1016/j.ijsu.2020.11.019

35. Tejedor P, Pastor C, Pellino G, et al. Management of acute diverticulitis with pericolic free gas (ADIFAS): an international multicenter observational study. International Journal of Surgery. 2023;109(4):689–697. doi: 10.1097/js9.0000000000000213