Diverticulitis Surgery Often Avoidable, New Standard Needed

Veronica Hackethal, MD

January 16, 2014

Complicated recurrence of diverticulitis is rare even after 2 acute episodes, and chronic symptoms often remain after colectomy, according to a systematic review published online January 15 in JAMA Surgery. The findings suggest nonsurgical approaches should be the standard of care.

"The prior standard for proceeding with elective colectomy following 2 episodes of diverticulitis is no longer accepted," Scott E. Regenbogen, MD, MPH, an assistant professor of surgery in the Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, and colleagues write. "Decisions to proceed with colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of the disease, and operative risk."

Diverticulitis treatment has improved during the last decade, according to the authors, because of advances in knowledge about the disease course and its nonsurgical management, and because of recognition of persisting postoperative morbidity. In 2000, American Society of Colon and Rectal Surgeons (ASCRS) guidelines recommended colectomy after 2 episodes of uncomplicated diverticulitis. By 2006, the ASCRS guidelines had started questioning this practice.

For the current review, the authors searched the National Guidelines Clearinghouse, PubMed, Cochrane databases, Web of Science Citation Index, and manual reference to identify studies about diverticulitis from between January 1, 2000, and March 31, 2013. They sought to identify evidence about diagnosis and management for acute, recurrent, and chronic diverticulitis. The researchers selected studies using the Preferred Reporting Items for Systematic Review and Meta-analyses method. The authors reviewed studies using guidelines from the Meta-analysis of Observational Studies in Epidemiology Group. They rated evidence level using American College of Cardiology/American Heart Association guidelines and compared recommendations with the most recent guidelines from the ASCRS.

Sixty-three studies met inclusion criteria. Complicated recurrence after an uncomplicated diverticulitis episode was found in less than 5% of cases, with most subsequent episodes similar in severity to previous ones. Risk for complications did not increase by age of onset younger than 50 years or by 2 or more episodes. Laparoscopic approaches seemed to be preferred, although randomized studies comparing open with closed techniques may have been limited by patient preference for laparoscopic surgery. Postoperative infections rates ranged from 5% to 10%, with mortality rates less than 5%. Chronic symptoms after resection were found in 5% to 22% of patients. The authors also included a computed tomography-based severity grading system for use in guiding decisions about disease resolution and recurrence.

The authors acknowledge that this review was limited by the overall quality of the evidence, as most of the studies were retrospective observational trials and epidemiological studies. Therapy comparisons were mainly observational and may have been prone to selection bias. Comparisons between studies were also hampered by variation in surgical technique, diagnosis, and study methodology.

Overall, studies supported individualizing decisions for surgery on the basis of evidence showing reductions in urgent surgery for acute diverticulitis, fewer indications for prophylactic colectomy, and a shift toward less invasive management of diverticulitis.

"[R]ecent evidence suggests the safety of avoiding elective colectomy for most patients with uncomplicated disease," the authors emphasize, adding that it "opens the door to modern approaches such as selective anastomosis with proximal diversion in the acute setting and laparoscopic colectomy in the elective setting."

The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online January 15, 2014. Abstract

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