The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Abstract

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Acute Pancreatitis: Diagnosis and Treatment

“…Despite enteral nutrition, bacterial translocation may still occur, an important although not the only route of infective complications, notably infecting necrosis; early infection is associated with increased mortality [200]. Prompt recognition, for example gas bubbles in necrosis on CECT, source control that may necessitate percutaneous drainage, appropriate antibiotics, physiological stabilisation, and optimal further interventional approaches are fundamental [201]. Nevertheless, during the first 4 weeks of acute pancreatitis inflammation, fluid collections and necrosis are diffuse, such that major interventions are less likely to be effective and can increase patient instability.…”

“…Nevertheless, during the first 4 weeks of acute pancreatitis inflammation, fluid collections and necrosis are diffuse, such that major interventions are less likely to be effective and can increase patient instability. The mainstay of treatment may need to be antibiotics appropriate to Gram-negative intra-abdominal infection, for example piperacillin-tazobactam or tigecycline or a third-generation cephalosporin with metronidazole [201]; the choice depends in part on the availability of samples for culture and patient response, best determined in consultation with clinical microbiologists. In the most severe disease, fungal infection is characteristic, may be brought on by extensive antibacterial treatments, and requires early and prolonged treatment with antifungals [202].…”

Diagnosing the acute abdomen during a global contrast shortage: a single centre experience

“…15 Despite the high prevalence of chronic kidney disease in the elderly population, a contrast-CT scan should not be discouraged as it facilitates a prompt diagnosis and treatment in this frail population. 16 Elevated WCC and CRP have been well established in AA pathology, especially when done pre-operatively. 17,18 The results of this study were not consistent with the literature.…”

“…This could be explained by the fact that patients with an acute abdomen are more likely to have a concurrent acute kidney injury or have underlying chronic kidney disease 15 . Despite the high prevalence of chronic kidney disease in the elderly population, a contrast‐CT scan should not be discouraged as it facilitates a prompt diagnosis and treatment in this frail population 16 . Elevated WCC and CRP have been well established in AA pathology, especially when done pre‐operatively 17,18 .…”

Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee

“…The prevalence of diverticular disease, that affects mostly the left and sigmoid colon, is similar in both sexes. Diverticulitis is the acute evolution of chronic diverticulosis and it can occur in about 10–25% of patients with diverticular disease [ 2 ]. Diverticulitis results from the inflammation of one or more diverticula, that may lead to a microscopic or gross perforation.…”