When and Why Do Diverticulitis Patients Need Surgery?

By Marilynn Larkin

November 25, 2020

NEW YORK (Reuters Health) - An update to the American Society of Colon and Rectal Surgeons (ASCRS) guideline on diverticular disease suggests that surgery may not be needed in many cases, while a study of laparoscopic resection shows that quality of life may improve, although risks exist.

A review of the guideline update and the study of laparoscopic surgery compared with conservative treatment are published in the November 18 issue of JAMA Surgery.

The update "suggests that a substantial number of (diverticulitis) patients can be successfully managed without surgery, and that a decision to proceed with elective surgery should not be based on stand-alone factors such as young age or the number of prior episodes," Dr. David Stewart of the University of Arizona in Tucson, who authored the guideline review, told Reuters Health by email.

The 2020 ASCRS clinical practice guideline (updated from 2014) was developed based on a systematic review of the literature from 2013-2019. A total of 168 articles (from 4,223) were included. Other recommendations include:

- Otherwise healthy patients with uncomplicated sigmoid diverticulitis can be safely managed without antibiotics (strong recommendation based on high-quality evidence).

- After successful nonoperative treatment of a diverticular abscess, elective surgery should be considered (strong recommendation based on moderate-quality evidence).

Despite the recommendation that surgery often can be avoided, a study from Finland published in the same issue found that "sigmoid resection improved quality of life significantly and almost completely prevented recurrences" in patients with recurrent diverticulitis, coauthor Dr. Sallinen of the University of Helsinki told Reuters Health by email.

Nonetheless, he said, "Our study fits quite nicely into the guideline, although our results may tilt the decisions towards favoring surgery more over non-surgical options. But we agree with the guidelines suggesting that the decision should be made through shared decision-making with the patient, taking into consideration the symptoms, lifestyle limitations and worries regarding recurrences, and also the risks of surgery."

The team's open-label clinical trial randomized 90 patients (mean age, 55; 69% women) to surgery or conservative treatment. At six months, quality-of-life outcomes were assessed for 37 patients who underwent surgery and 35 treated conservatively, whereas clinical outcomes were assessed for 41 surgery and 44 conservatively treated patients.

Gastrointestinal Quality of Life Index scores showed a mean difference of 11.96 in favor of surgery. On the clinical side, four patients (10%) in the surgery group and none in the conservative group had major complications (Clavien-Dindo grade III or higher). Two (5%) in the surgery and 12 (31%) in the conservative treatment group had new diverticulitis episodes.

Dr. Sallinen said, "Lately sigmoid resection has been used more seldom than, say, 10-15 years ago, because no clear evidence has been available to show its benefits. I would think that results of this study will increase the awareness of the benefits of laparoscopic sigmoid resection, and clinicians should consider this option more than they have before."

Nevertheless, there are risks, he acknowledged. "This is something that needs to be discussed with the patient before the decision to proceed to operation and also taken into consideration when balancing treatment options."

Commenting on the trial, Dr. Stewart said, "This study provides data that could be supportive of elective surgical intervention for patients with recurrent complaints of pain and with clinical data suggesting that diverticular disease is the likely cause of that pain, with a reasonable expectation that correctly selected surgical patients can expect an improved quality of life."

"The study also provides a reminder that major complications affect a minority of surgical patients, while no one receiving nonsurgical treatment experienced a complication," he said. "This also affects quality of life and should be considered by patients and physicians."

SOURCE: https://bit.ly/39gZKb9 and https://bit.ly/2KxDPlD JAMA Surgery, online November 18, 2020.