title: Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?
abstract: BACKGROUND
  Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patient's ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes.
  
  
  METHODS
  This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated.
  
  
  RESULTS
  Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis.
  
  
  CONCLUSIONS
  Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Andreas
authors.initials: A
authors.lastname: Brandl
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Theresa
authors.initials: T
authors.lastname: Kratzer
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Reinhold
authors.initials: R
authors.lastname: Kafka-Ritsch
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Eva
authors.initials: E
authors.lastname: Braunwarth
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Christian
authors.initials: C
authors.lastname: Denecke
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Sascha
authors.initials: S
authors.lastname: Weiss
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Georgi
authors.initials: G
authors.lastname: Atanasov
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Robert
authors.initials: R
authors.lastname: Sucher
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Matthias
authors.initials: M
authors.lastname: Biebl
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Felix
authors.initials: F
authors.lastname: Aigner
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Johann
authors.initials: J
authors.lastname: Pratschke
authors.affiliation: From the Department of Visceral, Transplant and Thoracic Surgery, Medical University, Innsbruck, Austria (Brandl, Kratzer, Kafka-Ritsch, Braunwarth, Weiss); the Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany (Brandl, Atanasov, Pratschke); and the Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany (Denecke, Sucher, Biebl, Aigner, Pratschke, Öllinger).
authors.forename: Robert
authors.initials: R
authors.lastname: Öllinger
mesh_terms: D000328:Adult; D000368:Aged; D004239:Diverticulitis, Colonic / Q000150:complications / Q000276:immunology / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors