Management of Acute Diverticulitis in Immunocompromised Patients—The Mayo Clinic Experience

Abstract

BACKGROUND: Acute diverticulitis in immunocompromised patients is associated with high morbidity and mortality rates with either medical or surgical treatment. Thus, management approach is controversial, especially for patients presenting with nonperforated disease. OBJECTIVE: This study aimed to report the Mayo clinic experience of acute diverticulitis management in immunocompromised patients. DESIGN: This design is based on a retrospective cohort study. SETTING: This study was conducted with institutional data composed from 3 tertiary referral centers. PATIENTS: Immunocompromised patients presenting with acute diverticulitis at 3 Mayo clinic sites between 2016 and 2020 were included. MAIN OUTCOME MEASURES: The main outcome measures were the management algorithm and short-term outcomes. RESULTS: Immunocompromised patients presenting with acute uncomplicated diverticulitis (86) were all managed nonoperatively at presentation with a success rate of 93% (80/86). Two patients (2.3%, 2/86) required surgery during the same admission, and 4 patients (4.8%, 4/84) had 30-day readmission. Complicated diverticulitis patients with abscess (22) were all managed nonoperatively first with a success rate of 95.4% (21/22). One patient (4.6%, 1/22) required surgery during the same admission. All the patients who presented with obstruction (2), fistula (1), or free perforation (11) underwent surgery except one who chose hospice. Overall, the major complication rate was 50% (8/16) and mortality rate was 18.8% (3/16) among patients who underwent surgery during the same admission. For patients who presented with perforated diverticulitis, the mortality rate was 27.3% (3/11), compared with 0% (0/111) for patients who presented with nonperforated disease. LIMITATIONS: This cohort was limited by its retrospective nature and heterogeneity of the patient population. CONCLUSIONS: Nonoperative management was safe and feasible for immunocompromised patients with colonic diverticulitis without perforation at our center. Perforated colonic diverticulitis in immunocompromised patients was associated with high morbidity and mortality rate. See Video Abstract at http://links.lww.com/DCR/B988. MANEJO DE LA DIVERTICULITIS AGUDA EN PACIENTES INMUNOCOMPROMETIDOS: EXPERIENCIA DE LA CLINICA MAYO ANTECEDENTES: La diverticulitis aguda en pacientes inmunocomprometidos se asocia con una alta tasa de morbilidad y mortalidad con el tratamiento médico o quirúrgico. Por lo tanto, el enfoque de manejo es controvertido, especialmente para pacientes que presentan enfermedad no perforada. OBJETIVO: El propósito fue informar la experiencia de la clínica Mayo en el manejo de la diverticulitis aguda en pacientes inmunocomprometidos. DISEÑO: Este es un estudio de cohorte retrospectivo ENTORNO CLÍNICO: Este estudio se realizó con datos institucionales compuestos de tres centros de referencia terciarios. PACIENTES: Se incluyeron pacientes inmunocomprometidos que presentaron diverticulitis aguda en tres sitios de la clínica Mayo entre 2016 y 2020. RESULT...

Acute diverticulitis in immunosuppressed patients: a 12‐year management experience

“…More recent evidence suggests that conservative management of immunosuppressed patients is safe and feasible 3,9 . In our cohort, the immunosuppressed patients that underwent conservative management had a similar rate of failure of conservative treatment as their immunocompetent counterparts (8% versus 5%).…”

“…When comparing the subgroup of these patients with paracolic or pelvic abscesses, there was still no significant difference in failure of conservative management with 20% and 13% failure rates respectively. A recent retrospective group by the Mayo clinic with 122 patients showed similar success with conservative management with 2% of immunosuppressed patients with uncomplicated diverticulitis and 5% of patients with abscesses failing conservative management 3 . The authors did not compare the immunosuppressed group to an immunocompetent cohort.…”

“…Management of acute diverticulitis can be challenging, particularly in immunosuppressed patients. In this cohort, healing can be impaired and systematic manifestations can be masked, secondary to immunosuppressive medications 3 . This understanding has led to surgeons having a lower threshold for operative management.…”

“…The severity of diverticulitis can vary from uncomplicated, such as thickening of the colonic wall, to complicated disease, with fistula, abscess, or perforation 3 . As such, the management of diverticulitis is tailored to patient acuity from conservative management with intravenous antibiotics to surgical resection 1 …”

“…Immunosuppressed patients are widely considered to have a higher incidence of acute diverticulitis and are more likely to develop free perforation and faeculent peritonitis 3,4 . Compared to immunocompetent patients, immunosuppressed patients are more likely to undergo emergency surgery at the first episode of diverticulitis, and also have worse mortality 5 .…”