- Email: [email protected]
Letter to the Editor on the article “Predictors of acute diverticulitis severity: A systematic review”
International Journal of Surgery 28 (2016) 69e70
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Letter to the Editor on the article “Predictors of acute diverticulitis severity: A systematic review”
Keywords: Acute diverticulitis Disease severity C-reactive protein
Dear Editor, With great interest I read the above mentioned review [1]. This study is of substantial clinical interest, as for first time, all the factors associated with acute diverticulitis (AD) severity are meticulously presented. Moreover it brings up the crucial issue of the lack of unanimity on what is complicated diverticulitis. Almost all studies are retrospective, and define as severe disease the presence of perforation in the CT-scan, or the need of operative/interventional therapy. Both end-points carry imperfections: CT-staging is very useful to guide therapeutic options, but it should be noted that CT-complicated disease is often successfully managed conservatively [2,3]. For this reason, it appears judicious to use the imaging findings suggesting complication as predictive factors for clinically complicated course, rather than as end-points themselves. Likewise, the need of invasive treatment has not been defined objectively in patients without generalized peritonitis or large abscess, therefore management policies vary considerably between Institutions [2e4]. We should not disregard the possibility that a CT-driven decision may result in potential invasive overtreatment in patients who might, otherwise, be successfully treated conservatively [2e4]. As the Authors imply, quality reporting will be assisted by improved definitions and terminology. In this respect, the idea of seeking to convert an urgent procedure to an elective one, or even to definite conservative therapy, is a sound clinical concept [3]. Accordingly, future research should focus on accurately determining and standardizing the clinical-laboratory predictors of the “failure of conservative management of the acute episode” in patients with the absence of diffuse peritonitis or large abscess. Moreover, the resolution of the acute event and the chronic sequelae of AD should be studied as separate target events. This may prevent confusion in the investigation of the relative risk factors, and will assist in the development of tailored therapeutic strategies. The C-reactive protein is associated with AD severity, however caution should be approached before investigating this factor in
meta-analysis and employing specific cut-off values. Other than the heterogeneity of reporting [1], most studies did not exclude from analysis important factors that influence CRP baseline levels [5,6]. As an example, advanced liver disease, and glucocorticoids may decrease the CRP response, while pre-hospital antibiotics, and chronic diverticulitis complications, may distort the CRP value on admission [7]. It should be mentioned that thiseotherwise excellent-review erroneously reports that the study by the undersigned and collaborators [4] did not perform a multivariate analysis, so the predictive strength of the white blood cell counteand of the other factors found to be significant in the univariate analysis-were not jointly evaluated in relation to AD severity. Inversely, the logistic regression analysis revealed that CRP >170 mg/l and Hinchey stage>I were independent predictors of operative/interventional treatment [4]. Our study excluded all cases with factors that affect CRP levels, however due to its retrospective design, it can not avoid the potential weaknesses discussed above. Sincerely. Ethical approval This communication to the Editor does not require any Ethical Approval. Funding No funding. Author contribution Aristotelis Kechagias was the only author of the communication. Conflicts of interest The author declares no conflicts of interest. Guarantor Aristotelis Kechagias MD. Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. References [1] J.P. Tan, A.W. Barazanchi, P.P. Singh, A.G. Hill, A.D. Maccormick, Predictors of acute diverticulitis severity: a systematic review, Int. J. Surg. 26 (2016 Jan 9) 43e52.
http://dx.doi.org/10.1016/j.ijsu.2016.02.067 1743-9191/© 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
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Letter to the Editor / International Journal of Surgery 28 (2016) 69e70
[2] V.J. Sallinen, P.J. Mentula, A.K. Lepp€ aniemi, Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients, Dis. Colon Rectum 57 (2014) 875e881. [3] S. Dharmarajan, S.R. Hunt, E.H. Birnbaum, J.W. Fleshman, M.G. Mutch, The efficacy of nonoperative management of acute complicated diverticulitis, Dis. Colon Rectum 54 (2011) 663e671. €kela €, The role of the C-reactive pro[4] A. Kechagias, T. Rautio, G. Kechagias, J. Ma tein in the prediction of the clinical severity of acute diverticulitis, Am. Surg. 80 (2014) 391e395. €ser, G. Fankhauser, P.M. Glauser, D. Toia, G.A. Maurer, Diagnostic value of [5] S.A. Ka inflammation markers in predicting perforation in acute sigmoid diverticulitis, World J. Surg. 34 (2010) 2717e2732. [6] B.M.J. van de Wall, W.A. Draaisma, R.T. van der Kaaij, E.C. Consten, M.J. Wiezer, I.A. Broeders, The value of inflammation markers and body temperature in acute diverticulitis, Colorectal Dis. 15 (2013) 621e626. [7] E. Nizri, S. Spring, A. Ben-Yehuda, M. Kharib, J. Klausner, R. Greenberg, C-reactive protein as a marker of complicated diverticulitis in patients on antiinflammatory medication, Technol. Coloproctol. 18 (2014) 145e149.
Aristotelis Kechagias* Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland *
Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland. E-mail address: [email protected]. 7 February 2016 Available online 22 February 2016
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
Letter to the Editor on the article “Predictors of acute diverticulitis severity: A systematic review”
Keywords: Acute diverticulitis Disease severity C-reactive protein
Dear Editor, With great interest I read the above mentioned review [1]. This study is of substantial clinical interest, as for first time, all the factors associated with acute diverticulitis (AD) severity are meticulously presented. Moreover it brings up the crucial issue of the lack of unanimity on what is complicated diverticulitis. Almost all studies are retrospective, and define as severe disease the presence of perforation in the CT-scan, or the need of operative/interventional therapy. Both end-points carry imperfections: CT-staging is very useful to guide therapeutic options, but it should be noted that CT-complicated disease is often successfully managed conservatively [2,3]. For this reason, it appears judicious to use the imaging findings suggesting complication as predictive factors for clinically complicated course, rather than as end-points themselves. Likewise, the need of invasive treatment has not been defined objectively in patients without generalized peritonitis or large abscess, therefore management policies vary considerably between Institutions [2e4]. We should not disregard the possibility that a CT-driven decision may result in potential invasive overtreatment in patients who might, otherwise, be successfully treated conservatively [2e4]. As the Authors imply, quality reporting will be assisted by improved definitions and terminology. In this respect, the idea of seeking to convert an urgent procedure to an elective one, or even to definite conservative therapy, is a sound clinical concept [3]. Accordingly, future research should focus on accurately determining and standardizing the clinical-laboratory predictors of the “failure of conservative management of the acute episode” in patients with the absence of diffuse peritonitis or large abscess. Moreover, the resolution of the acute event and the chronic sequelae of AD should be studied as separate target events. This may prevent confusion in the investigation of the relative risk factors, and will assist in the development of tailored therapeutic strategies. The C-reactive protein is associated with AD severity, however caution should be approached before investigating this factor in
meta-analysis and employing specific cut-off values. Other than the heterogeneity of reporting [1], most studies did not exclude from analysis important factors that influence CRP baseline levels [5,6]. As an example, advanced liver disease, and glucocorticoids may decrease the CRP response, while pre-hospital antibiotics, and chronic diverticulitis complications, may distort the CRP value on admission [7]. It should be mentioned that thiseotherwise excellent-review erroneously reports that the study by the undersigned and collaborators [4] did not perform a multivariate analysis, so the predictive strength of the white blood cell counteand of the other factors found to be significant in the univariate analysis-were not jointly evaluated in relation to AD severity. Inversely, the logistic regression analysis revealed that CRP >170 mg/l and Hinchey stage>I were independent predictors of operative/interventional treatment [4]. Our study excluded all cases with factors that affect CRP levels, however due to its retrospective design, it can not avoid the potential weaknesses discussed above. Sincerely. Ethical approval This communication to the Editor does not require any Ethical Approval. Funding No funding. Author contribution Aristotelis Kechagias was the only author of the communication. Conflicts of interest The author declares no conflicts of interest. Guarantor Aristotelis Kechagias MD. Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. References [1] J.P. Tan, A.W. Barazanchi, P.P. Singh, A.G. Hill, A.D. Maccormick, Predictors of acute diverticulitis severity: a systematic review, Int. J. Surg. 26 (2016 Jan 9) 43e52.
http://dx.doi.org/10.1016/j.ijsu.2016.02.067 1743-9191/© 2016 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
70
Letter to the Editor / International Journal of Surgery 28 (2016) 69e70
[2] V.J. Sallinen, P.J. Mentula, A.K. Lepp€ aniemi, Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients, Dis. Colon Rectum 57 (2014) 875e881. [3] S. Dharmarajan, S.R. Hunt, E.H. Birnbaum, J.W. Fleshman, M.G. Mutch, The efficacy of nonoperative management of acute complicated diverticulitis, Dis. Colon Rectum 54 (2011) 663e671. €kela €, The role of the C-reactive pro[4] A. Kechagias, T. Rautio, G. Kechagias, J. Ma tein in the prediction of the clinical severity of acute diverticulitis, Am. Surg. 80 (2014) 391e395. €ser, G. Fankhauser, P.M. Glauser, D. Toia, G.A. Maurer, Diagnostic value of [5] S.A. Ka inflammation markers in predicting perforation in acute sigmoid diverticulitis, World J. Surg. 34 (2010) 2717e2732. [6] B.M.J. van de Wall, W.A. Draaisma, R.T. van der Kaaij, E.C. Consten, M.J. Wiezer, I.A. Broeders, The value of inflammation markers and body temperature in acute diverticulitis, Colorectal Dis. 15 (2013) 621e626. [7] E. Nizri, S. Spring, A. Ben-Yehuda, M. Kharib, J. Klausner, R. Greenberg, C-reactive protein as a marker of complicated diverticulitis in patients on antiinflammatory medication, Technol. Coloproctol. 18 (2014) 145e149.
Aristotelis Kechagias* Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland *
Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland. E-mail address: [email protected]. 7 February 2016 Available online 22 February 2016