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  • Prognostic performance of the ‘DICA’ endoscopic classification and the ‘CODA’ score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study

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Original research
Prognostic performance of the ‘DICA’ endoscopic classification and the ‘CODA’ score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study
  1. Antonio Tursi1,2,
  2. Giovanni Brandimarte3,
  3. Francesco Di Mario4,
  4. Walter Elisei5,
  5. Marcello Picchio6,
  6. Leonardo Allegretta7,
  7. Maria Laura Annunziata8,
  8. Mauro Bafutto9,
  9. Gabrio Bassotti10,
  10. Maria Antonietta Bianco11,
  11. Raffaele Colucci12,
  12. Rita Conigliaro13,
  13. Dan Dumitrascu14,
  14. Ricardo Escalante15,
  15. Luciano Ferrini16,
  16. Giacomo Forti17,
  17. Marilisa Franceschi18,
  18. Maria Giovanna Graziani19,
  19. Frank Lammert20,
  20. Giovanni Latella21,
  21. Giovanni Maconi22,
  22. Gerardo Nardone23,
  23. Lucia Camara de Castro Oliveira24,
  24. Enio Chaves Oliveira25,
  25. Alfredo Papa26,
  26. Savvas Papagrigoriadis27,
  27. Anna Pietrzak28,
  28. Stefano Pontone29,
  29. Tomas Poskus30,
  30. Giuseppe Pranzo31,
  31. Matthias Christian Reichert20,
  32. Stefano Rodinò32,
  33. Jaroslaw Regula33,34,
  34. Giuseppe Scaccianoce35,
  35. Franco Scaldaferri36,
  36. Roberto Vassallo37,
  37. Costantino Zampaletta38,
  38. Angelo Zullo39,
  39. Daniele Piovani40,41,
  40. Stefanos Bonovas40,41,
  41. Silvio Danese42
  42. DICA International Group
    1. 1 Azienda Sanitaria Locale Barletta Andria Trani, Andria, Italy
    2. 2 Department of Medical and Surgical Sciences, Catholic University, Roma, Italy
    3. 3 Ospedale Cristo Re, Roma, Italy
    4. 4 Ospedale Maggiore di Parma, Parma, Italy
    5. 5 Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
    6. 6 Ospedale P Colombo, Velletri, Italy
    7. 7 Ospedale Santa Caterina Novella, Galatina, Italy
    8. 8 Istituto Policlinico San Donato, San Donato Milanese, Italy
    9. 9 Institute of Gastroenterology and Digestive Endoscopy, Goiânia, Brazil
    10. 10 Gastroenterology and Hepatology Section, San Sisto (Perugia), Italy
    11. 11 Ospedale T Maresca, Torre del Greco, Italy
    12. 12 Ospedale di San Matteo degli Infermi, Spoleto, Italy
    13. 13 Nuovo Ospedale Civile Sant'Agostino Estense di Baggiovara, Modena, Italy
    14. 14 2nd Medical Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania
    15. 15 Central University of Venezuela, Loira Medical Center, Caracas, Venezuela, Bolivarian Republic of
    16. 16 Casa di Cura Villa dei Pini, Civitanova Marche, Italy
    17. 17 Ospedale Santa Maria Goretti, Latina, Italy
    18. 18 AULSS 4 Alto Vicentino, Bassano del Grappa, Italy
    19. 19 Azienda Ospedaliera San Giovanni-Addolorata, Roma, Italy
    20. 20 Department of Medicine II, Saarland University Medical Center, Homburg, Germany
    21. 21 Division of Gastroenterology, Department of Life, Health & Environmental Sciences, Hepatology and Nutrition, "San Salvatore" Hospital, University of L'Aquila, L'Aquila, Italy
    22. 22 Azienda Ospedaliera L Sacco, Milan, Italy
    23. 23 Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
    24. 24 Department of Anorectal Physiology, 'São José” Home Care, Rio de Janeiro, Brazil
    25. 25 Department of Colorectal Surgery, Federal University of Goiás, Goiânia, Goiás, Brazil
    26. 26 Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
    27. 27 King's College London, London, UK
    28. 28 Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education and Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
    29. 29 Department of Surgical Sciences, 'Sapienza'-University of Rome, Roma, Italy
    30. 30 Institute of Clinical Medicine, Vilnius University Hospital, Vilnius, Lithuania
    31. 31 Ospedale Valle d'Itria, Martina Franca, Italy
    32. 32 Azienda Ospedaliera Pugliese Ciaccio, Catanzaro, Italy
    33. 33 Gastroenterology, Medical Centre for Postgraduate Education, Warsaw, Poland
    34. 34 Gastroenterology, the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
    35. 35 Ospedale di Altamura, Altamura, Italy
    36. 36 Department of Medical and Surgical Sciences, Internal Medicine, Gastroenterology Division, Catholic University of Rome, Roma, Italy
    37. 37 Division of Gastroenterology and Digestive Endoscopy, 'Bucchieri-La Ferla' Hospital, Palermo, Italy
    38. 38 Ospedale di Belcolle, Viterbo, Italy
    39. 39 Gastroenterology, Presidio Territoriale di Prossimità Nuovo Regina Margherita, Roma, Italy
    40. 40 Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
    41. 41 IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
    42. 42 Gastroenterology and Endoscopy, IRCCS Ospedale "San Raffaele" and University "Vita-Salute San Raffaele", Milano, Italy
    1. Correspondence to Professor Antonio Tursi, Azienda Sanitaria Locale Barletta Andria Trani, Andria, Puglia, Italy; antotursi{at}tiscali.it

    Abstract

    Objective To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).

    Design A multicentre, prospective, international cohort study.

    Setting 43 gastroenterology and endoscopy centres located in Europe and South America.

    Participants 2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.

    Interventions A 3-year follow-up was performed.

    Main outcome measures To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).

    Results The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).

    Conclusions DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.

    Trial registration number NCT02758860.

    • diverticular disease
    • endoscopy

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/gutjnl-2021-325574

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • Correction notice This article has been corrected since it published Online First. The author, Enio Chavez de Oliveira, and affiliation 41 and the collaborator group have been added.

      • Collaborators DICA International Group: Marco Astegiano, Division of Gastroenterology, “Molinette” University Hospital, Torino – Italy. Gianluca Baldassarre, Digestive Endoscopy Unit, ULSS7 Alto Vicentino, Santorso (VI) - Italy. Fabio Baldi†, Digestive Endoscopy Unit, Civil Hospital, Tarquinia (VT) – Italy. † deceased. Edoardo Borsotti, Division of Gastroenterology, “San Donato” Hospital, San Donato Milanese (MI) – Italy. Claudio Cassieri, Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Roma – Italy. Alessia Cazzato, Division of Gastroenterology, “Santa Caterina Novella” Hospital, Galatina (LE) - Italy. Stefania Chiri, Division of Gastroenterology, “Santa Caterina Novella” Hospital, Galatina (LE) - Italy. Antonio Ciccone,Department of Life, Health & Environmental Sciences, Division of Gastroenterology, Hepatology and Nutrition, San Salvatore Hospital, University of L'Aquila, L’Aquila. Debora Compare, Department of Clinical Medicine and Surgery, Division of Gastroenterology and Hepatology, Federico II” University Hospital, Naples - Italy. Alberto Damiani, Service of Digestive Endoscopy, “Villa dei Pini” Home Care, Civitanova Marche (MC) – Italy. Patrizia De Colibus, Division of Gastroenterology, “T. Maresca” Hospital, Torre del Greco (NA) - Italy. Roberto Faggiani, Division of Gastroenterology, “S. Camillo” Hospital, Roma - Italy. Fabio Finocchiaro, Division of Gastroenterology, “Molinette” University Hospital, Torino – Italy. Serafina Fiorella, Division of Gastroenterology, “San Pio da Pietrelcina” Hospital, Vasto (CH) - ItalyA. Francesca Foschia, Territorial Gastroenterology Service, ASL Roma 2, Roma – Italy. Federica Furfaro, IBD Unit, “Humanitas” University Hospital, Rozzano (MI) – Italy. Sara Gallina, Division of Gastroenterology, “Belcolle” Hospital, Viterbo – Italy. Gian Marco Giorgetti, Digestive Endoscopy and Nutritional Unit, “S. Eugenio” Hospital, Roma – Italy. Simona Grad, 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca – Romania. Giuseppe Grande, Digestive Endoscopy Unit, “Sant’Agostino Estense” Hospital, Baggiovara (MO) – Italy. Antonio Grandolfo, Division of Gastroenterology, “S. Paolo” Hospital, Bari - Italy. Maria Antonia Lai, Division of Gastroenterology – “Monserrato” University Hospital, University of Cagliari, Cagliari - Italy. Piera Giuseppina Lecca, Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Rome - Italy. Daniele Lisi, Digestive Endoscopy and Nutritional Unit, “S. Eugenio” Hospital, Rome - Italy; Territorial Gastroenterology Service, ASL Roma 2, Rome - Italy. Loris Riccardo Lopetuso, Division of Internal Medicine and Gastroenterology, IRCCS “A. Gemelli” Hospital, Fondazione Policlinico Gemelli, Catholic University, Roma – Italy. Antonio Penna, Division of Gastroenterology, “S. Paolo” Hospital, Bari - Italy. Piero Portincasa, Internal Medicine Unit, “A. Murri” Medical Clinic, Policlinico University Hospital, Bari - Italy. Giannenrico Rizzatti, Division of Internal Medicine and Gastroenterology, IRCCS “A. Gemelli” Hospital, Fondazione Policlinico Gemelli, Catholic University, Roma – Italy. Giovanni Luca Rizzo, Division of Gastroenterology, “Perrino” Hospital, Brindisi – Italy. Stefania Scanni, Territorial Gastroenterology Service, ASL Roma 2, Roma – Italy. Luigi Schiffino, Division of Gastroenterology and Surgical Endoscopy, “Grassi” Hospital, Ostia, Roma – Italy. Erasmo Spaziani, Department of Surgery, “Sapienza” University of Rome-Polo Pontino, Terracina (LT) – Italy. Ieva Stundiene, Institute of Clinical Medicine, Vilnius University Hospital, Vilnius - Lithuania. Antonino Tesoriere, Digestive Endoscopy Unit, Civil Hospital, Tarquinia (VT) - Italy. Gabriele Torti, Department of Medicine and Surgery, Gastroenterology and Hepatology Unit, “Santa Maria della Misericordia” University Hospital, University of Perugia, Perugia - Italy. Riccardo Urgesi, Division of Gastroenterology and Digestive Endoscopy “S. Giovanni-Addolorata” Hospital, Roma - Italy. Paolo Usai, Division of Gastroenterology – “Monserrato” University Hospital, University of Cagliari, Cagliari – Italy.

      • Contributors Guarantor of the Article: AT; Authorship Conception and design: AT; FDM, GB, E.S.; Acquisition and collection of data: AT, GB, WE, LA, MLA, MA, MB, F, B†, GB, MAB, RC, RC, DD, RE, RF, LF, SF, GF, MF, GM, SG, MGG, MAL, FL, GL, DL, GM, GN, LCCO, ECO, AP, SP, AP, AP, SP, PP, TP, GP, MCR, GLR, SR, JR, GS, FS, LS, IS, RV, CZ, AZ, SD, GB, EB, CC, AC, SC, AC, DC, AD, PDC, FF, FF, FF, SG, GG, AG, PGL, LRL, FP, GR, SS, AT, GT, RU,PU; Analysis and interpretation of data: AT, WE, MP, DP, SB, SD; Final approval of the version to be published: AT, GB, WE, LA, MLA, MA, MB, F, B†, GB, MAB, RC, RC, DD, RE, RF, LF, SF, GF, MF, GM, SG, MGG, MAL, FL, GL, DL, GM, GN, LCCO, ECO, AP, SP, AP, AP, SP, PP, TP, GP, MCR, GLR, SR, JR, GS, FS, LS, IS, RV, CZ, AZ, SD, GB, EB, CC, AC, SC, AC, DC, AD, PDC, FF, FF, FF, SG, GG, AG, PGL, LRL, FP, GR, SS, AT, GT, RU, PU.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests SD served as speaker, consultant and/or advisory board member for AbbVie, Allergan, Alfa Wassermann, Biogen, Boehringer Ingelheim, Celgene, Celltrion, Ferring, Gilead, Hospira, Johnson and Johnson, Merck, MSD, Mundipharma, Pfizer, Sandoz, Takeda, Tigenix, UCB Pharma, Vifor. GM served as speaker and/or advisory board fees for AlfaSigma, Arena, Janssen, Gilead, Roche. GN received funding for target projects from Apharm and Sofar. APserved as lecturer for AlfaSigma and Polpharma. JR served as lecturer for AlfaSigma, Takeda, Ipsen and Servier. FS served as lecturer for Sanofi.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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