New Indications for Laparoscopic Sigmoidectomy

Badma Bashankaev; Steven D. Wexner

Disclosures

Current recommendations for the performance of laparoscopic sigmoidectomy in patients with diverticulitis reserve this procedure for individuals who have complications of the disease or have had numerous, severe disease episodes. Findings from a 2009 study challenge this dogma and suggest that patients' quality of life should also be considered.

One of the chief goals of elective surgery is to treat conditions in a manner that optimizes postoperative quality of life for the patient. The critical elements of the mandatory, preoperative, informed-consent process, therefore, include a thorough discussion of the various potential benefits, risks, complications and alternatives to surgery associated with a particular procedure. Thus, surgeons must present in detail all these issues in a comprehensive and balanced manner. The patient may ultimately rely upon the surgeon to select the best treatment approach for their condition; however, surgeons traditionally estimate the value of their work by quantification of objective parameters, such as disease-free survival, morbidity and mortality. This value system might be quite different to the patient's own expectations, which may have a particular focus on quality of life.[1]

Although scales and measurements of functional status after surgery have been used since the beginning of the 20th century, the three chief facets that contribute to quality of life are physical, social and psychological well being. The contribution of these components to quality of life was not thoroughly researched or evaluated with reliable metrics until the implementation of governmental initiatives in the middle of the 20th century. The US National Health Examination Survey, as it was termed when introduced in 1957, intended to measure the medical quality of life of the population of North America. Approximately 800 questionnaires were implemented to measure generic and disease-specific health-related quality of life. After this initial effort, the quality of life of patients after various surgical procedures was extensively researched.[2,3]

The advent of laparoscopic surgery greatly accelerated the use of quality-of-life studies. As most surgical procedures can be performed using either an open or a laparoscopic technique with similar efficacy and quantitative clinical outcomes, improvement of quality of life has become a new benchmark of surgical success. One of the areas for which laparoscopy has clearly shown a therapeutic benefit is sigmoid colectomy for diverticulitis. Laparoscopic management of diverticulitis has demonstrated important clinical and quantitative benefits with regard to operative blood loss, postoperative pain, length of hospital stay, morbidity and mortality compared with open surgical techniques.[4,5,6]

Forgione and colleagues have now provided an interesting perspective on the indications for surgical management of sigmoid diverticulitis.[7] In this study, elective laparoscopic sigmoidectomy was performed in 46 patients after a single documented attack of diverticulitis. This prospective clinical trial is the first to report on the quality of life of patients with confirmed diverticulitis before and after standardized laparoscopic sigmoidectomy.

Historically, elective surgical treatment of diverticulitis was reserved for the treatment of disease complications, such as perforation, abscess, fistula or obstruction. With the progress and evolution of surgical expertise and perioperative support during the 1970s and 1980s, the indications for colonic resection were broadened to enable surgical management of 'uncomplicated' diverticulitis. Specifically, surgical resection was recommended for the amelioration of symptoms such as chronic, left iliac fossa pain that could be accompanied by a change in the patient's bowel habits. Data from studies performed before the current decade demonstrated that only 10–30% of patients who were hospitalized for acute diverticulitis were rehospitalized for subsequent episodes of the disease. Moreover, <50% of patients who were hospitalized with complicated diverticulitis had a history of diverticular disease. Importantly, if an elective sigmoid resection was performed, the incidence of persistent symptoms or serious complications was not significantly better than that seen in conservatively treated patients.[8] These findings eventually led to a shift in the treatment paradigm towards one that was against the use of prophylactic resection for diverticular disease. Current recommendations for the management of diverticulitis are mostly based on the clinical manifestation of the disease and rely upon use of a quantitative approach to assess the risk of disease recurrence and complications. The practice parameters published by the American Society of Colon and Rectal Surgeons (ASCRS) suggest that the decision to recommend surgery should be influenced by the patient's age and medical condition, the frequency and severity of diverticulitis episodes, and whether symptoms persist after the acute episode. The ASCRS also states that surgical management is indicated after two or more well-documented attacks of diverticulitis.[9] These recommendations are based on findings from retrospective studies, which showed that after one attack, a minority of patients will have an additional attack of acute diverticulitis. A second attack reportedly increased the chances of a third attack, which was itself associated with an increased risk of colostomy.

In our opinion, the relatively low incidence of morbidity following laparoscopic sigmoid colectomy compared with laparotomy for diverticulitis has enhanced the acceptance of such resections among surgeons, referring physicians and patients. Thus, the treatment paradigm may shift again, from one that avoids surgery for patients who do not have multiple attacks of complicated diverticulitis towards one that promotes the use of pre-emptive and prophylactic resections to avoid the development of such complications in the first instance.

The well-designed study by Forgione et al. used mainly subjective indications for surgery. This expert evaluation raised the question of whether patient-centered indications for surgery that address quality of life should be implemented. The authors used several assessment tools, including the gastrointestinal quality-of-life indicator (GIQLI), the international prostate-symptom score, the international index of erectile function and the urinary-distress inventory, both before the patient underwent surgery and regularly during the first year thereafter. Through use of these validated tools, the investigators elegantly demonstrated that GIQLI scores were considerably impaired in many patients who had at least one attack of acute diverticulitis, and that these scores often improved after the patient underwent elective surgery.

The design, data analysis, interpretation of results, and conclusion of the study by Forgione et al. are thorough and well-formed. Clearly, the surgeon must consider the potential overall benefit to the individual patient. Although the desire to pre-empt perforation or avoid a stoma may be a part of the surgical algorithm, the ability to improve quality of life has been convincingly demonstrated and now must also be factored into care of patients, particularly if surgery can be done with the expectation of rapid, postoperative recovery and a low incidence of morbidity.

However, further quality-of-life studies are needed, especially as the incidence of admissions for diverticulitis in the US alone has increased by 26% over the past 7 years, in the context of a steady decrease in the age of patients at admission.[10] Although this provocative study by Forgione and colleagues might change the timing and reasons for surgical resection in patients with diverticulitis, additional studies to confirm their findings will undoubtedly be undertaken. For now, however, the authors should be congratulated on having challenged the dogma of our current practice with highly credible data.


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