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Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis

  • R. Cirocchi
  • J. J. Randolph
  • G. A. Binda
  • S. GioiaEmail author
  • B. M. Henry
  • K. A. Tomaszewski
  • M. Allegritti
  • A. Arezzo
  • R. Marzaioli
  • P. Ruscelli
Review Article
  • 73 Downloads

Abstract

Background

In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.

Methods

A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.

Results

This systematic review included 21 studies including 1781 patients who had outpatient management of AD  including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.

Conclusions

The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.

Keywords

Acute diverticulitis Outpatient Uncomplicated diverticulitis Outpatient management 

Notes

Acknowledgements

The authors thank Nereo Vettoretto and Vito D’Andrea for their assistance.

Funding

This study did not benefit of any source of funding.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study a formal consent is not required.

Supplementary material

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Supplementary material 1 (DOCX 17 KB)
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Supplementary material 2 (DOCX 29 KB)
10151_2018_1919_MOESM3_ESM.docx (16 kb)
Supplementary material 3 (DOCX 15 KB)
10151_2018_1919_MOESM4_ESM.doc (63 kb)
Supplementary material 4 (DOC 63 KB)

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Surgical ScienceUniversity of PerugiaPerugiaItaly
  2. 2.Georgia Baptist College of NursingMercer UniversityAtlantaUSA
  3. 3.Department of SurgeryGalliera HospitalGenoaItaly
  4. 4.Section of Legal MedicineAOSP TerniTerniItaly
  5. 5.Cincinnati Children’s Hospital Medical CenterCincinnatiUSA
  6. 6.International Evidence-Based Anatomy Working GroupKrakówPoland
  7. 7.Interventional Radiology UnitAOSP TerniTerniItaly
  8. 8.Department of Surgical SciencesUniversity of TurinTurinItaly
  9. 9.Department of Emergency and Organ Transplantation (DETO)University Medical School “A. Moro” BariBariItaly
  10. 10.Emergency Surgery Unit, Faculty of Medicine and Surgery, Torrette HospitalPolytechnic University of MarcheAnconaItaly

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