Surgical management in immunosuppressed patients with sigmoid diverticulitis, still a challenge: a single-center observational study

Abstract

Purpose The question of whether immunosuppressed (IS) patients should be offered elective sigmoidectomy following a single episode of diverticulitis is controversial. We intended to examine the perioperative outcome of IS and immunocompetent (IC) patients after sigmoid resection. Methods A single institutional cohort study was conducted, including all surgically treated patients with sigmoid diverticulitis between 2004 and 2021. IS and IC patients were further subdivided into emergency and elective cases. Morbidity and mortality in both groups and factors influencing surgical outcome were examined using uni- and multivariate regression analyses. Results A total of 281 patients were included in the final analysis. Emergency surgery was performed on 98 patients while 183 patients underwent elective sigmoid resection. Emergency sigmoidectomy demonstrates significantly higher morbidity and mortality rates in IS patients as compared to IC patients (81.81% vs. 42.1%; p = 0.001, respectively 27.27% vs. 3.94%; p = 0.004), while major morbidity and mortality was similar in both groups in the elective setting (IS: 23.52% vs. IC: 13.85%; p = 0.488, respectively IS: 5.88% vs. IC: 0%; p = 1). On multivariate regression analysis for major postoperative morbidity, ASA score [OR 1.837; (95% CI 1.166–2.894); p = 0.009] and emergency surgery under immunosuppression [OR 3.065; (95% CI 1.128–8.326); p = 0.028] were significant. In-hospital mortality was significantly related to age [OR 1.139; (95% CI 1.012–1.282); p = 0.031], preoperative CRP count [OR 1.137; (95% CI 1.028–1.259); p = 0.013], and immunosuppression [OR 35.246; (95% CI 1.923–646.176), p = 0.016] on multivariate analysis. Conclusions Elective surgery for sigmoid diverticulitis in immunocompromised patients demonstrates higher efficacy and safety when compared to sigmoid resection in the emergency setting.

Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group

“…We also observed an increased mortality rate in IMS compared to IC, 5.1% versus 0.6%, respectively ( p < 0.001) which is consistent with the finding reported by Vaghiri et al. that found a rate of 27% in IMS group versus 3% in IC [35] and McKechnie et al. who showed a mortality rate between 4.4%–20% in initially nonoperative management diverticulitis in IMS [32].…”

Comparative outcomes of acute colonic diverticulitis in immunocompromised versus immunocompetent patients: a systematic review and meta-analysis

“…Table 1 lists the characteristics of the 10 included studies. 7,8,[18][19][20][21][22][23][24][25] Totals of 5,339 immunocompromised patients and 1,941,122 immunocompetent patients with acute diverticulitis requiring www.irjournal.org hospitalization were analyzed. The study period was 1988 to 2021.…”

“…Seven of the 10 studies included patients with sigmoid or left colonic diverticulitis. 7,8,[18][19][20][21]24 One study included all patients with left or right colonic diverticulitis, but most had sigmoid diverticulitis. 22 The remaining 2 studies did not clarify the location of diverticulitis, but it is presumed that most patients had left colonic diverticulitis considering the contents of their analysis.…”

“…Nine of the included studies reported mortality rates. 7,8,[18][19][20][21][22][23][24] The overall mortality after acute colonic diverticulitis irrespective of surgical intervention was 4.7% in immunocompromised patients and 1.5% in immunocompetent patients. Meta-analysis revealed that the immunocompromised patients had a significantly higher risk of overall mortality (RR, 3.65; 95% CI, 1.73-7.69) (Z = 3.40, P = 0.0007, I 2 = 94%).…”

“…Diverticulitis Four studies reported postoperative morbidities including surgical site infection, wound dehiscence, anastomotic leakage or stenosis, intraabdominal abscess, sepsis, ileus, postoperative bleeding, and cardiovascular, pulmonary, thromboembolic, and renal and urinary tract complications. 18,21,22,24 The rates of postoperative morbidities after elective colonic resection in immunocompromised and immunocompetent patients were 26.6% and 12.3%, respectively. Immunocompromised patients with diverticulitis had a greater risk of postoperative morbidity than immunocompetent patients (RR, 2.07; 95% CI, 1.83-2.34) in the meta-analysis (Z = 11.58, P < 0.00001, I 2 = 45%) (Fig.…”