Association between colonic polyps and diverticular disease

AIM: To evaluate the association between colonic polyps and diverticular disease in Japan. METHODS: We retrospectively reviewed the medical records of 672 consecutive patients who underwent total colonoscopy between August 2006 and April 2007 at Nishinjo Hospital, Okinawa, Japan. Patients with a history of any of the following were excluded from the study: previous polypectomy, colonic resection, and inflammatory bowel diseases. The association between colonic polyps and diverticular disease was analyzed by logistic regression analysis, adjusted for age and sex. RESULTS: Prevalence of colonic polyps in all patients with diverticular disease was significantly higher than that in those without diverticular disease (adjusted odds ratio 1.7). CONCLUSION: Our data showed that patients with diverticular disease have a higher risk of colonic polyps compared to those without.

Diet,ageing and genetic factors in the pathogenesis of diverticular disease

Diverticular disease(DD) is an age-related disorder of the large bowel which may affect half of the population over the age of 65 in the UK.This high prevalence ranks it as one of the most common bowel disorders in western nations.The majority of patients remain asymptomatic but there are associated life-threatening co-morbidities, which, given the large numbers of people with DD, translates into a considerable number of deaths per annum.Despite this public health burden, relatively little seems to be known about either the mechanisms of development or causality.In the 1970s, a model of DD formulated the concept that diverticula occur as a consequence of pressureinduced damage to the colon wall amongst those with a low intake of dietary fiber.In this review, we have examined the evidence regarding the influence of ageing, diet, inflammation and genetics on DD development.We argue that the evidence supporting the barotrauma hypothesis is largely anecdotal.We have also identified several gaps in the knowledge base which need to be filled before we can complete a model for the etiology of diverticular disease.

Demographic determinants of risk,colon distribution and density scores of diverticular disease

AIM:To investigate associations between ethnicity,age and sex and the risk,colon distribution and density scores of diverticular disease(DD).METHODS:Barium enemas were examined in 1000 patients:410 male,590 female;760 whites,62 Asians,44 black africans(BAs),and 134 other blacks(OBs).Risks and diverticula density of left-sided DD(LSDD) and rightsided-component DD(RSCDD = right-sided DD + right and left DD + Pan-DD) were compared using logistic regression.RESULTS:Four hundred and forty-seven patients had DD(322 LSDD and 125 RSCDD).Adjusted risks:(1) LSDD:each year increase in age increased the odds by 6%(95% CI:5-8,SE:0.8%,P < 0.001);Asians:odds ratio(OR):0.23(95% CI:0.10-0.53,SE:0.1,P ≤ 0.001) and OBs:OR:0.25(95% CI:0.14-0.43,SE:0.07,P ≤ 0.001) appeared protected vs Whites;(2) RSCDD:each year increase in age increased the odds by 4%(95% CI:2-6,SE:1%,P < 0.001);females were 0.60 times(95% CI:0.40-0.90,SE:0.12,P = 0.01) less likely than males to have RSCDD;BAs were 3.51 times(95% CI:1.70-7.24,SE:1.30,P < 0.001) more likely than Whites to have RSCDD;and(3) DD density scores:each year increase in age increased the odds of highdensity scores by 4%(95% CI:1-6,SE:1%,P < 0.001);RSCDD was 2.77 times(95% CI:1.39-3.32,SE:0.67,P < 0.001) more likely to be of high density than LSDD.No further signif icant differences were found in the adjusted models.CONCLUSION:Right colonic DD might be more common and has higher diverticula density in the west than previously reported.BAs appear predisposed to DD,whereas other ethnic differences appear conserved following migration.

Abundance of Enterobacteriaceae in the colon mucosa in diverticular disease

AIM To compare gut bacterial diversity and amount of Enterobacteriaceae in colonic mucosa between patients with and without diverticular disease(DD).METHODS Patients in a stable clinical condition with planned elective colonoscopy were included. Blood samples and colon mucosa biopsies were collected at the colonoscopy. Study questionnaires including questions about gastrointestinal symptoms were completed by the patients and physicians. DNA from mucosa samples was isolated and the amount of Enterobacteriaceae was estimated using PCR assay. Terminal restriction frag mentlength polymorphism was applied to assess microbial diversity. Diversity was estimated by calculations of richness(number of terminal restriction fragments) and Shannon-Wiener and Simpson's indices. RESULTS A total of 51 patients were included, 16 patients with DD [68(62-76) years] and 35 controls [62(40-74) years] without any diverticula. Patients with DD had significantly higher levels of Enterobacteriaceae than those without DD(P = 0.043), and there was an inverse relationship between the amount of Enterobacteriaceae and the Simpson's index(rs =-0.361, P = 0.033) and the Shannon-Wiener index(rs =-0.299, P = 0.081). The Simpson's index(P = 0.383), Shannon-Wiener index(P = 0.401) or number of restrictions fragments(P = 0.776) did not differ between DD and controls. The majority of patients experienced gastrointestinal symptoms, and 22 patients(43.1%) fulfilled the criteria for irritable bowel syndrome, with no difference between the groups(P = 0.212). Demography, socioeconomic status, lifestyle habits, inflammatory biomarkers, or symptoms were not related to the amount of Enterobacteriaceae or bacterial diversity. CONCLUSION Patients with DD had higher amount of Enterobacteriaceae in the colon mucosa compared to patients without diverticula.

High-fibre diet and Lactobacillus paracasei B21060 in symptomatic uncomplicated diverticular disease

AIM： To investigate in symptomatic uncomplicated di- verticular disease the efficacy of symbiotics associated with a high-fibre diet on abdominal symptoms. METHODS： This study was a multicentre, 6-too ran- domized, controlled, parallel-group intervention with a preceding 4-wk washout period. Consecutive out- patients with symptomatic uncomplicated diverticular disease, aged 40-80 years, evaluated in 4 Gastroenterology Units, were enrolled. Symptomatic uncomplicated diverticular disease patients were randomized to two treatment arms A or B. Treatment A （n = 24 patients） received 1 symbiotic sachet Flortec~ （Lactobacillus paracasei B21060） once daily plus high-fibre diet for 6 mo. Treatment B （n = 21 patients） received high-fibre diet alone for 6 rno. The primary endpoint was regres- sion of abdominal symptoms and change of symptom severity after 3 and 6 mo of treatment. RESULTS： In group A, the proportion of patients with abdominal pain 〈 24 h decreased from 100% at base- line to 35% and 25% after 3 and 6 mo, respectively （P 〈 0.001）. In group B the proportion of patients with this symptom decreased from 90.5% at baseline to 61.9% and 38.1% after 3 and 6 mo, respectively （P = 0.001）. Symptom improvement became statistically sig- nificant at 3 and 6 mo in group A and B, respectively. The proportion of patients with abdominal pain 〉24 h decreased from 60% to 20% then 5% after 3 and 6 too, respectively in group A （P 〈 0.001） and from 33.3% to 9.5% at both 3 and 6 mo in group B （P = 0.03）. In group A the proportion of patients with ab- dominal bloating significantly decreased from 95% to 60% after 3 mo, and remained stable （65%） at 6-mo follow-up （P = 0.005） while in group B, no significant changes in abdominal bloating was observed （P = 0.11）. After 6 mo of treatment, the mean visual analogic scale （VAS） values of both short-lasting abdominal pain （VAS, mean ± SD, group A： 4.6 ± 2.1 vs 2.2 ± 0.8, P = 0.02; group B： 4.6 ± 2.9 vs 2.0 ± 1.9, P = 0.03） and abdom- inal bloating （VAS, mean ± SD, group A： 5.3 ± 2.2 vs 3.0 ± 1.7, P = 0.005; group B： 5.3 ±3.2 vs 2.3 ± 1.9, P = 0.006） decreased in both groups, whilst the VAS values of prolonged abdominal pain decreased in the Flortec group, but remained unchanged in the high-fibre diet group （VAS, mean ± SD, group A： 6.5 ± 1.5 vs 4.5 ± 2.1, P = 0.052; group B： 4.5 ± 3.8 vs 5.5 ± 3.5）. CONCLUSION： A high-fibre diet is effective in relievingabdominal symptoms in symptomatic uncomplicated di- verticular disease. This treatment may be implemented by combining the high-fibre diet with Flortec~.

Current surgical treatment of diverticular disease in the Netherlands

AIM: To evaluate the development of diagnostic tools, indications for surgery and treatment modalities concerning diverticular disease (DD) in the Netherlands. METHODS: Data were collected from 100 patients who underwent surgery for DD in three Dutch hospitals. All hospitals used the same standardized data base. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into two groups, one undergoing elective surgery (elective group) and the other undergoing acute surgery (acute group). RESULTS: Two hundred and ninety-nine patients were admitted between 2000 and 2007. One hundred and seventy-eight patients underwent acute surgery and 121 patients received elective operations. The median age of the 121 patients was 69 years (range: 28-94 years), significantly higher in acute patients (P = 0.010). Laparoscopic resection was performed in 31% of elective patients. In the acute setting, 61% underwent a Hartmann procedure. The overall morbidity and mortality were 51% and 10%, and 60% and 16% in the acute group, which were significantly higher than in the elective group (36% and 1%). Only 35% of the temporary ostomies were restored. CONCLUSION: This study gives a picture of current surgical practice for DD in the Netherlands. New developments are implemented in daily practice, resulting in acceptable morbidity and mortality rates.

Health related quality of life after surgery for colonic diverticular disease

Diverticular disease(DD) of the colon is very common in developed countries and is ranked the fifth most important gastrointestinal disease worldwide.The management of acute diverticulitis without perforation and peritonitis is still debated.Health related quality of life(HRQL),subjectively perceived by patients,is becoming a major issue in the evaluation of any therapeutic intervention,mainly in patients with chronic disease.To date only a few published studies can be found on Medline examining HRQL in patients with DD.The aim of this study was to review the impact of surgery for DD on HRQL.All Medline articles regarding HRQL after surgery for colonic DD,particularly those comparing different surgical approaches,were reviewed.DD has a negative impact on HRQL with lower scores in bowel function and systemic symptoms.Both surgery-related complications and disease activity have a significant impact on patients' HRQL.While no signif icant differences in HRQL between different operations for DD in non-randomized studies were revealed,the only prospective double-blind randomized study that compared laparoscopic and open colectomy found that patients undergoing laparoscopic colectomy had signif icantly reduced major postoperative complication rates and subsequently had better HRQL scores.Formal assessment of HRQL could be a good instrument in the selection of appropriate patients for elective surgery as well as in the assessment of surgical outcome.

Appendicitis combined with Meckel’s diverticulum obstruction, perforation, and inflammation in children: Three case reports

BACKGROUND Meckel’s diverticulum is a common congenital malformation of the small intestine,with the three most common complications being obstruction,per-foration,and inflammation.To date,only a few cases have been reported world-wide.In children,the clinical symptoms are similar to appendicitis.As most of the imaging features are nonspecific,the preoperative diagnosis is not precise.In addition,the clinical characteristics are highly similar to pediatric acute appendicitis,thus special attention is necessary to distinguish Meckel’s diver-ticulum from pediatric appendicitis.Patients with poor disease control should undergo laparoscopic exploration to avoid serious complications,including intestinal necrosis,intestinal perforation and gastrointestinal bleeding.CASE SUMMARY This report presents three cases of appendicitis in children combined with intestinal obstruction,which was caused by fibrous bands(ligaments)arising from the top part of Meckel's diverticulum,diverticular perforation,and diver-ticular inflammation.All three patients,aged 11-12 years,had acute appendicitis as their initial clinical presentation.All were treated by laparoscopic surgery with a favorable outcome.A complete dataset including clinical presentation,dia-gnostic imaging,surgical information,and histopathologic findings was also provided.CONCLUSION Preoperative diagnosis of Meckel’s diverticulum and its complications is challenging because its clinical signs and complications are similar to those of appendicitis in children.Laparoscopy combined with laparotomy is useful for diagnosis and treatment.

Use of rifaximin in gastrointestinal and liver diseases

Rifaximin is a broad spectrum oral antibiotic with antimicrobial activity against Gram-positive and Gram-negative aerobic and anaerobic bacteria. It is poorly absorbed and thus has a highly favorable safety profile. Rifaximin has been shown to be effective in the treatment of traveler&#x02019;s diarrhea, functional bloating and irritable bowel syndrome, small bowel bacterial overgrowth and in the prevention of recurrent overt hepatic encephalopathy. In addition, there is emerging evidence for a possible beneficial effect of rifaximin in the treatment of uncomplicated diverticular disease and in the prevention of recurrent diverticulitis. The use of rifaximin is associated with a low incidence of development, or persistence of spontaneous bacterial mutants. Moreover, the development of important drug resistance among extra-intestinal flora during rifaximin therapy is unlikely because of minimal systemic absorption and limited cross-resistance of rifaximin with other antimicrobials. This review addresses the current and emerging role of rifaximin in the treatment of gastrointestinal and liver disorders.

Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding

BACKGROUND Colonoscopy within 24 h of hospital admission for colonic diverticular bleeding(CDB)is recommended.However,little is known about rates of rebleeding within 30 d.We posited that a group of patients who underwent contrast-enhanced computed tomography(CT)within 4 h of the last hematochezia and colonoscopy within 24 h would experience fewer incidences of rebleeding.AIM To evaluate the outcomes of early colonoscopy for CDB among different groups of patients.METHODS Data from 182 patients with CDB who underwent contrast-enhanced CT and colonoscopy between January 2011 and December 2018 at the study site were retrospectively reviewed.Patients were divided into groups based on the timing of the CT imaging,within or at 4 h were defined as urgent CTs(n=100)and those performed after 4 h were defined as elective CTs(n=82).Main outcomes included rebleeding within 30 d and the identification of stigmata of recent hemorrhage(SRH)(i.e.,active bleeding,non-bleeding visible vessels,or adherent clots).RESULTS In total,182 patients(126 men and 56 women)with median ages of 68.6(range,37-92)and 73.7(range,48-93)years,respectively,underwent CT imaging and colonoscopy within 24 h of the last hematochezia.Patients for whom CT was performed within 4 h of the last hematochezia were included in the urgent CT group(n=100)and patients for whom CT was performed after 4 h were included in the elective CT group(n=82).SRH were identified in 35.0%(35/100)of the urgent CT cases and 7.3%(6/82)of the elective CT cases(P<0.01).Among all patients with extravasation-positive images on CT,SRH was identified in 31 out of 47 patients(66.0%)in the urgent CT group and 4 out of 20 patients(20.0%)in the elective CT group(P<0.01).Furthermore,rates of rebleeding within 30 d were significantly improved in the urgent CT and extravasation-positive cases(P<0.05).Results from the evaluation of early colonoscopy did not show a difference in the ability to detect SRH identification or rebleeding rates.Only cases by urgent CT reduced risk of rebleeding due to the evidence of active bleeding on the image.CONCLUSION To improve rates of rebleeding,colonoscopy is recommended within 24 h in patients with extravasation-positive CT images within 4 h of the last hematochezia.Otherwise,elective colonoscopy can be performed.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey Ⅱ sigmoid colon diverticulitis: A case report

BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound(EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.CASE SUMMARY A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography(CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey Ⅱ diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient’s general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.CONCLUSION We report the first successful management of a pelvic abscess in patient with Hinchey Ⅱ acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Diverticulitis is a population health problem:Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings,and the prevalence of diverticulitis has increased.Historically,patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes.Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed,and many clinical practice guidelines(CPGs)have pivoted to recommend outpatient management and individualized decisions about surgery.Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States,suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease.In this review,we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Computed tomography colonography in 2014:An update on technique and indications

Twenty years after its introduction, computed tomographic colonography (CTC) has reached its maturity, and it can reasonably be considered the best radiological diagnostic test for imaging colorectal cancer (CRC) and polyps. This examination technique is less invasive than colonoscopy (CS), easy to perform, and standardized. Reduced bowel preparation and colonic distention using carbon dioxide favor patient compliance. Widespread implementation of a new image reconstruction algorithm has minimized radiation exposure, and the use of dedicated software with enhanced views has enabled easier image interpretation. Integration in the routine workflow of a computer-aided detection algorithm reduces perceptual errors, particularly for small polyps. Consolidated evidence from the literature shows that the diagnostic performances for the detection of CRC and large polyps in symptomatic and asymptomatic individuals are similar to CS and are largely superior to barium enema, the latter of which should be strongly discouraged. Favorable data regarding CTC performance open the possibility for many different indications, some of which are already supported by evidence-based data: incomplete, failed, or unfeasible CS; symptomatic, elderly, and frail patients; and investigation of diverticular disease. Other indications are still being debated and, thus, are recommended only if CS is unfeasible: the use of CTC in CRC screening and in surveillance after surgery for CRC or polypectomy. In order for CTC to be used appropriately, contraindications such as acute abdominal conditions (diverticulitis or the acute phase of inflammatory bowel diseases) and surveillance in patients with a long-standing history of ulcerative colitis or Crohn&#x02019;s disease and in those with hereditary colonic syndromes should not be overlooked. This will maximize the benefits of the technique and minimize potential sources of frustration or disappointment for both referring clinicians and patients.

Logical hypothesis:Low FODMAP diet to prevent diverticulitis

Despite little evidence for the therapeutic benefits of a high-fiber diet for diverticulitis, it is commonly recommended as part of the clinical management. The ongoing uncertainty of the cause(s) of diverticulitis confounds attempts to determine the validity of this therapy. However, the features of a high-fiber diet represent a logical contradiction for colon diverticulitis. Considering that Bernoulli&rsquo;s principle, by which enlarged diameter of the lumen leads to increased pressure and decreased fluid velocity, might contribute to development of the diverticulum. Thus, theoretically, prevention of high pressure in the colon would be important and adoption of a low FODMAP diet (consisting of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help prevent recurrence of diverticulitis.

Quality of life after surgery of the alimentary tract

In recent decades, patient-reported outcomes have become important in clinical medicine. Nowadays, health-related quality of life (HRQOL) is considered a primary outcome in many clinical trials, and it is often the major criterion for judging treatment success. At the beginning of the 21st century, morbidity and mortality rates after surgery of the alimentary tract have dropped dramatically and they can no longer be considered the only outcome measures to determine the success of a surgical procedure. QOL can yield a definitely more patient-orientated measure of outcome that provides us with a more formal measure of the patient’s judgment and desires, which can influence treatment decisions. Nevertheless, despite a very large number of published papers on HRQOL, there is some skepticism on the value of HRQOL and other patientrelated outcomes. Therefore, this topic highlight aims to assess how QOL after surgery of the alimentary tract is covered in the medical literature. Different reviews have analyzed the topic according to different points of view: benign and malignant disease; curative and palliative treatment; open and minimally invasive surgical approach; traditional and newly introduced surgical procedures. This topic highlight does not aim to cover all the possible diseases or different surgical procedures, but it does describe the different approaches in order to give the reader a broad spectrum of analysis of QOL after surgery. This quick overview could stimulate the reader to form his/her own opinion about how to use this primary outcome measure.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography

BACKGROUND Computed tomography colonography(CTC)may be superior to colonoscopy and barium enema for detecting diverticula.However,few studies have used CTC to diagnose diverticula.AIM To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC.METHODS This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial,which included 1181 participants from 14 hospitals in Japan.We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex.The relationship between the diverticula and the length of the large intestine was also analyzed.RESULTS Diverticulosis was present in 48.1%of the participants.The prevalence of diverticulosis was higher in the older participants(P<0.001 for trend).The diverticula seen in younger participants were predominantly located in the right-sided colon.Older participants had a higher frequency of bilateral type(located in the rightand left-sided colon)diverticulosis(P<0.001 for trend).The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula(P<0.001).CONCLUSION The prevalence of colonic diverticulosis in Japan is higher than that previously reported.The prevalence was higher,and the distribution tended to be bilateral in older participants.

Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective,singlecenter study of a prospectively maintained colorectal surgery database.All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis.Other indications for Hartmann’s procedures were excluded.Patients underwent open(OHR) or laparoscopic Hartmann’s reversal(LHR) between 2000 and 2010,and received the same pre-and post-operative protocols of cares.Operative variables,length of stay,short-(at 1 mo) and long-term(at 1 and 3 years) postoperative complications,and surgery-related costs were compared between groups.RESULTS: The OHR group consisted of 18 patients(13 males,mean age ± SD,61.4 ± 12.8 years),and the LHR group comprised 28 patients(16 males,mean age 54.9 ± 14.4 years).The mean operative time and the estimated blood loss were higher in the OHR group(235.8 ± 43.6 min vs 171.1 ± 27.4 min;and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively,P = 0.001).Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group,and 3 ± 1.3 d in the LHR group(P = 0.01).The length of hospital stay was significantly longer in the OHR group(11.2 ± 5.3 d vs 6.7 ± 1.9 d,P 【 0.001).The 1 mo complication rate was 33.3% in the OHR(6 wound infections) and 3.6% in the LHR group(1 hemorrhage)(P = 0.004).At 12 mo,the complication rate remained significantly higher in the OHR group(27.8% vs 10.7%,P = 0.03).The anastomotic leak and mortality rates were nil.At 3 years,no patient required re-intervention for surgical complications.The OHR procedure had significantly higher costs(+56%) compared to the LHR procedure,when combining the surgery-related costs and the length of hospital stay.CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays,complication rates,and costs compared to OHR.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice.They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes.As the incidence of complicated diverticular disease and colorectal malignancy increases,so too does the extent of fistulous connections between the gastrointestinal and urinary systems.These complex problems will be more common as a factor of an aging population with increased life expectancy.Diverticular disease is the most commonly encountered aetiology,accounting for up to 80%of cases,followed by colorectal malignancy in up to 20%.A high index of suspicion is required in order to make the diagnosis,with ever improving imaging techniques playing an important role in the diagnostic algorithm.Management strategies vary,with most surgeons now advocating for a single-stage approach to enterovesical fistulae,particularly in the elective setting.Concomitant bladder management techniques are also disputed.Traditionally,open techniques were the standard;however,increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management.Unfortunately,due to the relative rarity of these entities,no randomised studies have been performed to ascertain the most appropriate management strategy.Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer.With radiotherapy being a major contributing factor in the development of these complex fistulae,optimum surgical approach and exposure has changed accordingly to optimise their management.Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling,macerated tissues or associated co-morbidities.One may plan for definitive surgical intervention at a later stage.Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available.An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described.In low lying fistulae,a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts.According to recent literature,it offers a high success rate in complex cases.

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic?A scoping review

BACKGROUND Acute colonic diverticulitis(ACD)is common in Western countries,with its prevalence increasing throughout the world.As a result of the coronavirus disease 2019(COVID-19),elective surgery and in-patients’visits have been cancelled or postponed worldwide.AIM To systematically explore the impact of the pandemic in the management of ACD.METHODS MEDLINE,Embase,Scopus,MedxRiv,and the Cochrane Library databases were searched to 22 December 2020.Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible.For cross sectional studies,outcomes of interest included the number of hospital admission for ACD,as well as key features of disease severity(complicated or not)across two time periods(pre-and during lockdown).RESULTS A total of 69 papers were inspected,and 21 were eligible for inclusion.Ten papers were cross sectional studies from seven world countries;six were case reports;three were qualitative studies,and two review articles.A 56%overall decrease in admissions for ACD was observed during lockdown,peaking 67%in the largest series.A 4%-8%decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase.An initial non-operative management was recommended for complicated diverticulitis,and encouraged to an out-of-hospital regimen.Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination,societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained.CONCLUSION During the COVID-19 pandemic,fewer patients presented and were diagnosed with ACD.Such decline may have likely affected the spectrum of uncomplicated disease.Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.