Maziar Nikberg

No antibiotics in acute uncomplicated diverticulitis: does it work?

Abstract Background. The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence. Methods. This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Västmanland Hospital Västerås, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence. Results. In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year. Conclusion. The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.

Circumferential resection margin as a prognostic marker in the modern multidisciplinary management of rectal cancer.

BACKGROUND: A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer. OBJECTIVE: The purpose of this study was to analyze the involvement of circumferential resection margin in local recurrence and survival in a multidisciplinary population-based setting by using tailored oncological therapy and surgery with total mesorectal excision. DESIGN: Data were collected in a prospective database and retrospectively analyzed. Between 1996 and 2009, 448 patients with rectal cancer underwent a curative bowel resection. SETTINGS: Population-based data were collected at a single institution in the county of Västmanland, Sweden. RESULTS: Preoperative radiotherapy was delivered to 334 patients (74%); it was delivered to 35 patients (8%) concomitantly with preoperative chemotherapy. In 70 patients (16%), en bloc resections of the prostate and vagina were performed. Intraoperative perforations were seen in 7 patients (1.6%). The mesorectal fascia was assessed as complete in 117/118 cases. In 32 cases (7%), the circumferential resection margin was 1 mm or less. After a median follow-up of 68 months, 5 (1.1%) patients developed a local recurrence; one of them had circumferential resection margin involvement. The 5-year overall survival was 77%. In the multivariate analysis, the circumferential resection margin was not an independent factor for disease-free survival. LIMITATIONS: Mesorectal fascia was not assessed before 2007. The findings might be explained by a type II error but, from a clinical perspective, enough patients were included to motivate the conclusion of the study. CONCLUSIONS: Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.

Lymphovascular and perineural invasion in stage II rectal cancer : a report from the Swedish colorectal cancer registry

Abstract Background: Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level. Materials and methods: Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012. Results: Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09–1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34–2.43, p < .001) had significantly increased risks of recurrence. Conclusions: Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings

Abstract Purpose: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. Methods: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model. Results: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469). Conclusions: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Erratum to: Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study.

The original version of this article unfortunately contains an error in page 4, third line of the first paragraph under “Discussion” section. which reads, “The previous studies does not only strengthen that the non-antibiotic policy...”. It should read, “This study does not only strengthen previous studies that the non-antibiotic policy...”. The correct sentence is presented as below: “This study does not only strengthen previous studies that the non-antibiotic policy in acute uncomplicated diverticulitis is safe and applicable in clinical practice, but it also adds evidence that it is safe to discharge patients directly from the emergency department.”

Non-operative management of perforated diverticulitis with extraluminal or free air – a retrospective single center cohort study

Abstract Objectives: The aim of this study was to describe patient characteristics and results of non-operative management for patients presenting with computed tomography (CT) verified perforated diverticulitis with extraluminal or free air. Methods: All patients treated for diverticulitis (ICD-10: K-57) during 2010–2014 were identified and medical records were reviewed. Re-evaluations of CT examinations for all patients with complicated disease according to medical records were performed. All patients diagnosed with perforated diverticulitis and extraluminal or free air on re-evaluation were included and characteristics of patients having immediate surgery and those whom non-operative management was attempted are described. Results: Of 141 patients with perforated diverticulitis according to medical records, 136 were confirmed on CT re-evaluation. Emergency surgical intervention within 24 h of admission was performed in 29 (21%) patients. Non-operative management with iv antibiotics was attempted for 107 patients and was successful in 101 (94%). The 30-day mortality rate was 2%. The presence of a simultaneous abscess was higher for patients with failure of non-operative management compared with those that were successfully managed non-operatively (67% compared to 17%, p = .013). Eleven out of thirty-two patients (34%) with free air were successfully managed conservatively. Patients that were operated within 24 h from admission were more commonly on immunosuppressive therapy, had more commonly free intraperitoneal air and free fluid in the peritoneal cavity. Conclusions: Non-operative management is successful in the majority of patients with CT-verified perforated diverticulitis with extraluminal air, and also in one-third of those with free air in the peritoneal cavity.