Outcomes After Medical and Surgical Treatment of Diverticulitis: A Systematic Review of the Available Evidence

George Peppas; Ioannis A Bliziotis; Dora Oikonomaki; Matthew E Falagas

Disclosures

J Gastroenterol Hepatol. 2007;22(9):1360-1368. 

In This Article

Discussion

The available data from the studies included in our review support that current medical and surgical therapy of acute diverticulitis is effective in the great proportion of patients and that mortality is generally low in both treatment groups. In addition, reported mortality in both treatment groups was almost zero in the studies that evaluated younger patients (<50 years).[15,17,19,24,28] Although there are no definitive criteria regarding the choice of therapy, the type of disease (complicated vs uncomplicated), the age of the patient, and his/her general medical condition are the main factors that influence the physicians' choice. Patients with complicated forms of diverticular disease and especially peritonitis were treated by surgery in almost all of the included studies. In addition, in some studies, it was clarified that patients with a bad general medical condition were preferentially treated conservatively.[8,20] In studies that evaluated patients of younger age, the proportion of patients treated surgically (or conservatively while planned for an elective surgery) was generally high.[15,17,19,24,28]

The analysis of the included studies showed that recurrence and especially readmission due to diverticular disease was more common in patients treated conservatively compared to those treated surgically within the studies. Parks et al., in their cornerstone study regarding the natural course of diverticular disease, reported that readmission due to recurrent diverticulitis was 25% in 317 conservatively-treated patients.[29] The respective proportion in our analysis was 18.6%, showing that current medical therapy has not substantially decreased the recurrence of diverticular disease. However, given the fact that the prevalence of symptomatic diverticular disease is increasing in the Western world and especially among younger patients, one may postulate that the proportion of recurrence in our analysis should have been higher than that of the older series. Thus, although recurrence has only slightly decreased, this may actually represent a success for the current medical treatment.

Nevertheless, one may claim that surgery is probably the preferable management strategy for patients with diverticulitis who have risk factors for frequent recurrences of the disease. On the basis of the assumption that the rate of recurrence after an episode of diverticulitis is similar between the various age groups, it is expected that younger people, who have a longer life expectancy, will also have more chance of developing recurrences of diverticulitis during their lives. Earlier studies have confirmed this increase in the recurrence of acute diverticulitis and have also reported that diverticulitis in young patients may have a more aggressive course.[29,30,31] Many studies have been performed to examine the above hypotheses in young patients and the results seem rather contradictory, especially regarding the virulence of diverticular disease in younger patients.[25,28,32]

Our review was not designed to examine the aforementioned questions specifically in young patients with diverticulitis. Nevertheless, in the studies that followed up young patients with diverticulitis for a long period of time, the reported readmissions due to recurrence were higher than the average proportion of recurrences from all studies, both for surgical[15,24] and medical therapy.[15,24,28] In addition, Ambrosetti et al.,[8] Anaya et al.,[10] and Broderick Villa et al.[13] found that the relapse of acute diverticulitis or the development of complications after discharge in the medical group was statistically and significantly more common in younger patients, whereas Biondo et al.,[12] in a study designed to examine this question, found no difference. It is noteworthy that the proportion of conservatively-treated young patients that were ultimately operated on during follow up varied considerably in the three studies included in our review that reported on this outcome.[17,18,24]

Data from the large study by Broderick-Villa et al.[13] support that that the recurrence rate after an initial episode of diverticulitis treated medically is about 1.5% per year. Also, the mean age of patients with the first episode of diverticulitis is approximately 65 years, and such patients have an average life expectancy of 14 years. Thus, the calculated probability for a typical patient with the first episode of diverticulitis to develop recurrence of the disease during his/her rest of the life is approximately 21%. These facts suggest that if an operation had been performed for all patients with the first episode of diverticulitis, then the surgical management of diverticulitis would not have offered any specific advantages compared to medical treatment in 79% of these patients. However, as mentioned before, this is not true for younger patients in whom life expectancy, and subsequently, the calculated probability to develop recurrence of the disease is higher. In addition, Anaya et al.[10] found that even after adjusting for age, younger patients (<50 years) are at a 46% higher risk (hazard ratio 1.46) for recurrent hospitalizations compared to older patients.[10]

All of the above findings must be evaluated in the context of the benefits that may be achieved by a conservative approach, even for young patients. An overview of the analyzed studies shows that in the majority of patients presenting with a form of diverticulitis for which medical therapy is an option (i.e. uncomplicated acute diverticulitis or complications, such as hemorrhage and small abscesses), surgery may be avoided. Data from the studies focusing on young patients suggested that less than 45% of the patients treated only conservatively when elective treatment was an option would eventually need operative treatment during follow up.[24] In addition, less than 24% would need to undergo emergency surgery for diverticular disease.[24] Furthermore, it should be noted that although mortality in patients treated by elective surgery is generally very low, the studies report some complications in this group of patients.[17] Finally, the possible need for a stoma after surgery, which is a feared situation especially in the younger age groups, is gradually diminishing since resection and primary anastomosis during the same operation is becoming more widely used.[19]

Our study has several limitations. The most important limitation is that the comparative studies we included in our review were not randomized controlled trials, and thus a safe conclusion regarding the comparative success of the conservative and surgical management of patients with diverticulitis cannot be made. Also, the available data allowed for comparisons between patients treated surgically on an emergency basis and those treated medically, but there were not enough data regarding the comparison of the outcomes of patients undergoing elective surgery and those receiving medical treatment. Patients treated surgically on an emergency basis are usually more ill (since a significant proportion of them suffer from generalized peritonitis) compared to patients undergoing medical therapy. Thus, especially regarding the comparison of mortality, the analysis of data serves mainly descriptive purposes and does not intend to provide a direct comparison between the effectiveness of surgical and medical treatments. Another limitation of our review is that the populations in the included studies presented considerable heterogeneity regarding age and localization and the severity of the disease. In addition, there were no homogeneous predefined criteria for the type of treatment provided to the patients in the included studies, with the exception of generalized peritonitis that is by definition a surgical emergency. Furthermore, the follow up of patients varied considerably between the studies. Finally, the proportion of patients treated by different surgical techniques varied between the studies.

Conclusively, current medical and surgical therapy of acute diverticulitis is effective for the great proportion of patients, and mortality is generally low. Although mortality seems to be higher in patients undergoing emergency surgery than those treated conservatively, this finding should be attributed to the larger proportion of patients with severe forms of disease in the first group. Medical treatment results in more readmissions due to the recurrence of disease. However, it is reasonable to avoid surgical therapy in the vast majority of patients with acute diverticulitis and its milder forms of complications. This is because the calculated probability for a typical patient (older than 60 years) with the first episode of diverticulitis to develop recurrence of the disease during his/her rest of the life is low. It is unclear what the best treatment option for younger patients (<50 years) is and whether elective surgery after the first episode should be considered.


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