Systematic Reviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Mar 28, 2015; 5(1): 155-166
Published online Mar 28, 2015. doi: 10.5412/wjsp.v5.i1.155
Operative management of acute diverticulitis in immunosuppressed compared to immunocompetent patients: A systematic review
Ahmed Al-Khamis, Jad Abou Khalil, Nazi Torabi, Marie Demian, Abbas Kezouh, Philip H Gordon, Marylise Boutros
Ahmed Al-Khamis, Jad Abou Khalil, Marie Demian, Philip H Gordon, Marylise Boutros, Division of Colorectal Surgery, Jewish General Hospital, McGill University, Montreal, Quebec H3T 1E2, Canada
Nazi Torabi, Schulich Library of Science and Engineering, McGill University, Montreal, Quebec H3A 0C1, Canada
Abbas Kezouh, Department of Statistics and Epidemiology, Jewish General Hospital, Montreal, Quebec H3T 1E2, Canada
Author contributions: Al-Khamis A and Khalil JA made the substantial contributions to conception and design of the study, acquisition of data, and analysis and interpretation of data; drafting the article; Torabi N contributed to conception and design of the study, acquisition of data; making critical revisions related to important intellectual content of the manuscript; Demian M contributed to acquisition of data, drafting the article; Kezouh A contributed to review of the statistical methods; Gordon PH and Boutros M contributed to conception and design of the study, acquisition of data, and analysis and interpretation of data; making critical revisions related to important intellectual content of the manuscript.
Conflict-of-interest: We have no relevant disclosures.
Data sharing: Review protocol and dataset available from the corresponding author at mboutros@jgh.mcgill.ca. Consent was not required nor obtained but the presented data are anonymized and risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Marylise Boutros, MD, FRCS(C), Division of Colorectal Surgery, Jewish General Hospital, McGill University, 3755 Cote Ste Catherine G-314, Montreal, Quebec H3T 1E2, Canada. mboutros@jgh.mcgill.ca
Telephone: +1-514-3408222 Fax: +1-514-3407560
Received: October 9, 2014
Peer-review started: October 9, 2014
First decision: November 14, 2014
Revised: December 4, 2014
Accepted: February 4, 2015
Article in press: February 9, 2015
Published online: March 28, 2015
Abstract

AIM: To determine short and long-term outcomes following operative management of acute diverticulitis in immunosuppressed (IMS) compared to immunocompetent (IMC) patients.

METHODS: PRISMA guidelines were followed in conducting this systematic review. We searched PubMed (1946 to present), OVID MEDLINE(R) In-Process and Other Non-Indexed Citations, OVID MEDLINE(R) Daily and OVID MEDLINE(R) (1946 to present), EMBASE on OVID platform (1947 to present), CINAHL on EBSCO platform (1981 to present), and Cochrane Library using a systematic search strategy. There were no restrictions on publication date and language. We systematically reviewed all published cohort comparative studies, case-control studies, and randomized controlled trials that reported outcomes on operative management of acute episode of colonic diverticulitis in IMS in comparison to IMC patients.

RESULTS: Seven hundred and fifty-five thousand five hundred and eighty-three patients were included in this systematic review; of which 1478 were IMS and 754105 were IMC patients. Of the nine studies included there was one prospective cohort, seven retrospective cohorts, one retrospective case-control study, and no randomized controlled trials. With the exception of solid organ transplant patients, IMS patients appeared to be older than IMC when they presented with an acute episode of diverticulitis. IMS patients presented with more severe acute diverticulitis and more insidious onset of symptoms than IMC patients. In the emergency setting, peritonitis was the main indication for operative intervention in both IMS and IMC patients. IMS patients were more likely to undergo Hartmann’s procedure and less likely to undergo reconstructive procedures compared to IMC patients. Furthermore, IMS patients had higher morbidity and mortality rates in the emergency setting compared to IMC patients. In the elective settings, it appeared that reconstruction with primary anastomosis with or without a diverting loop stoma is the procedure of choice in the IMS patients and carried minimal morbidity and mortality equivalent to IMC patients.

CONCLUSION: Emergency operations for diverticulitis in IMS compared to IMC patients have higher morbidity and mortality, whereas, in the elective setting both groups have comparable outcomes.

Keywords: Diverticular disease, Immunosuppression, Diverticulitis, Chemotherapy, Transplant, Steroids

Core tip: Immunosuppressed (IMS) patients present with more severe episodes of diverticulitis compared to immunocompetent patients and are at increased risk of an emergency operation. However, IMS patients have a vague disease presentation with insidious onset. The postoperative morbidity and mortality following emergency operations for diverticulitis is worse in the IMS patient population, whereas, in the elective setting, the morbidity and mortality is comparable to the general population.