Visceral to Subcutaneous Fat Ratio Predicts Acuity of Diverticulitis

Salvatore Docimo Jr., DO1, Young Lee2, Praveen Chatani2, Ann M Rogers1, Frank J Lacqua3. 1Penn State Hershey Medical Center, 2St. George’s University, 3NYU Lutheran Medical Center

Introduction: Obesity is increasingly recognized as a risk factor for complicated diverticular disease.  As adipose tissue secretes inflammatory cytokines such as tumor necrosis factor-α and interleukin-6, one likely mechanism linking obesity and more severe diverticular disease is chronic inflammation.  Evidence suggests an association between visceral fat and complicated diverticular disease.   We have applied a quantitative measure of visceral fat content in patients who underwent emergent and elective surgical procedures for diverticulitis.

Methods: A retrospective review of all adult diverticulitis patients with an associated CT scan who underwent emergent or elective surgery from 2010 to 2014 was performed with institutional review board approval. Data was collected on demographics, co-morbidities, vital signs, operative findings, complications and length of stay (LOS). Radiologic measurements of adiposity were obtained from preoperative CT scans using Osirix DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space. The CT attenuation level to delineate the regions of adipose tissue was set using Hounsfield units  -190 to – 30.  The VFA to SFA ratio (V/S) was calculated.  Statistical analysis was performed using Student’s T-test and Fisher’s exact test.

Results: Thirty-four patients underwent emergent and 32 patients underwent elective surgery for diverticular disease.  The mean age was 66 for the emergent and 57.84  for the elective  group. Most patients were Caucasian: (21/34) in the emergent and  (16/32) in the elective group.  The perinephric , visceral, subcutaneous fat, and V/S ratio for the emergent group was 1.71, 185.22, 338.22, and 0.56 and 1.11, 127.18, 295.28, and 0.46 for the elective group.  The difference between the V/S ratio for each group was statistically significant (p = 0.0238).  The emergent group had an average LOS of 16.11 days compared to 5.11 for the elective group (p = <0.00001). The complication rate was significantly higher (p = 0.024) in the emergent group (n=10, 29.4%) compared to the elective group (n=2, 6.25%).

Conclusion: Our study demonstrates a clinically significant link between the level of visceral fat and the severity of diverticulitis.  Patients with higher V/S fat ratios were more likely to undergo emergency surgery for diverticulitis, have more complications and a longer LOS.  Larger studies evaluating the effect of weight loss surgery on the incidence of diverticulitis and the possibility of recommending weight loss surgery in the setting of diverticulosis should be explored.

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