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IN THE NEWS
GENERAL SURGERY NEWS / AUGUST 2021
Surgery for Diverticulitis: Who, When and How Still Up for Debate continued from page 1
become increasingly complex, said moderator Jason Patients who have more frequent attacks or disabling Hall, MD, MPH, an associate professor of surgery pain with attacks, or struggle with finances, work or and the co-director of the Dempsey Center for Diges- social life due to diverticulitis may benefit from surgery, tive Disorders at Boston University. “(Now) we often he said, adding that some patients want surgery because spend long, long minutes in the office, reviewing lots of they miss too many days of work from their disease or options for management with our patients.” receive repeated hospital bills related to this condition, For patients who are not acutely ill but have had at he said. He advised surgeons to take these quality-ofleast one episode of uncomplicated diverticulitis, sur- life issues into account. The decision to operate is “very geons should use patient-centered outcomes when much individualized based on the patient’s quality of deciding whether to operate, said Sean Langenfeld, life and priorities,” he said. MD, an associate professor and the chief of colon and “And when the time comes, sigmoid colectomy rectal surgery at the University of Nebraska Medi- works,” Dr. Langenfeld added, noting that the risk for cal Center, in Omaha. “In 2021, when you think about recurrent diverticulitis after colectomy is between 4% good reasons to operate, you can summarize it in three and 6%. Studies show patients’ quality of life improves words—quality of life,” he said. with surgery versus conservative management (Ann Elective sigmoid colectomies should be performed to Surg 2019;269[4]:612-620). improve quality of life rather than to prevent a future An ongoing randomized trial may yield more definhypothetical emergency, Dr. Langenfeld said. Quality of itive answers about the value of surgery in this populife should take priority over traditional onal objeclation. The COSMID study is a multicenter, tive metrics such as the number of attacks ttacks Ameri American trial designed to compare the or CT findings, he added. best medical care and sigmoid colectoThe standard of care for diverticcm my for patients who are asymptomulitis patients has changed markatic after recurrent uncomplicated edly over the past two decades. In diverticulitis or those who expethe past, surgery was recommendrience ongoing symptoms for ed for anyone who had a second more than three months after an attack of diverticulitis, or was index attack. younger than 50 years of age or “This is a fundamentally key immunocompromised at the first question for us as colorectal surepisode. In addition, for patientss ggeons as we see so many patients who did not have surgery, antibiottlik like this,” said co-principal investiics were given as standard, reflecting cting gato gator Thomas E. Read, MD, a profestso the belief that diverticulitis resultsor and the chief of gastrointestinal ed from microperforation and infecsurgery at the University of Florida ‘Diverticulitis has a very College of Medicine, in Gainesville. tion. However, in 2014, the ASCRS changed its guideline on surgery for Investigators plan to enroll 500 wide spectrum of disease diverticulitis, saying the decision to patients and assign them to surtype and severity, and operate should be individualized to gery or medical management with the patient and not based on the there is no one single rule a variety of tools including diet and number of attacks. exercise, fiber supplementation, proin terms of treatment.’ Recommendations are still evolvbiotics and rifamycin/mesalazine, ing, surgeons said during the session said principal investigator David —Dana M. Hayden, MD, MPH titled “Management of Diverticulitis. Flum, MD, MPH, a professor of Is There Anything We Were Taught surgery and the director of the UniThat Is True?” versity of Washington’s Surgical Outcomes Research Today, emerging evidence suggests that diverticuli- Center, in Seattle. All patients will complete the GIQLI tis arises from chronic inflammation of the gut and not at randomization and again at six, nine and 12 months infection (Gastroenterology 2019;156[5]:1282-1298.e1). after treatment. Moreover, recurrences after uncomplicated diverticulitis Investigators are looking to include patients treated are less frequent than previously estimated: Nonopera- at large and small hospitals, in rural and urban environtive management of acute uncomplicated diverticulitis ments, and a mix of academic and community practices. is successful in more than 95% of patients, Dr. Langen- Surgeons interested in participating are asked to contact feld said. This suggests that diverticulitis is not a pro- one of the investigators, Dr. Flum said. gressive disease, he noted. Fifteen hospitals in the United States are currently As understanding of diverticulitis evolved, surgery enrolling patients. The first results from the trial are became reserved for a more selected group of patients. expected after 2024. But exactly who and when and how are still up for Uncomplicated Diverticulitis: What to Do debate.
Uncomplicated Diverticulitis: When to Operate? Dr. Langenfeld said clinicians should use the Gastrointestinal Quality of Life Index (GIQLI)—a 36-point, validated health-related quality of life tool—to capture patient-centered outcomes like pain, appetite, reflux, social interaction and sexual function in patients with uncomplicated diverticulitis.
When You Don’t Operate The standard for medical therapy for patients with acute, uncomplicated diverticulitis also is in flux, said Fergal Fleming, MD, an associate professor of surgery and oncology at the University of Rochester, in New York. Contrary to traditional surgical dogma, not all nonsurgical patients require admission, antibiotics or medical therapy, he said. Two randomized controlled
trials—AVOD (Antibiotics in Acute, Uncomplicated Diverticulitis) and DIABOLO (Diverticulitis: AntiBiotics Or cLose Observation)—showed no significant differences in rates of recurrent diverticulitis, complicated diverticulitis, emergency colectomy, or elective colectomy for patients who received antibiotics or observation alone (Br J Surg 2012;99[4]:532-539; Br J Surg 2017;104[1]:52-61). “We need to move much more toward individualized medicalized therapy for patients with acute uncomplicated diverticulitis,” Dr. Fleming said. He noted that no conclusive data support clear fluids or a low-residue diet in patients with acute diverticulitis. According to the 2020 ASCRS clinical guideline, mesalamine was not found to reduce recurrent attacks in a meta-analysis of six randomized controlled trials, but rifaximin and fiber supplementation may reduce symptoms. Long-term use of nonsteroidal anti-inflammatory drugs should be avoided (Dis Colon Rectum 2020;63[6]:728-747).
Complicated Diverticulitis: Does It Always Require Surgery? Not all patients with complicated presentations of diverticulitis need surgery, said Dana M. Hayden, MD, MPH, the chief of colon and rectal surgery at Rush University Medical Center, in Chicago. Patients who are most likely to need surgery have larger abscesses, or have fistulas and strictures, which are more challenging and less effectively treated endoscopically, she said. Patients are less likely to require surgery after diverticular bleeding or if they have smaller abscesses associated with diverticulitis. “Diverticulitis has a very wide spectrum of disease type and severity, and there is no one single rule in terms of treatment,” Dr. Hayden said. When patients need emergency resection, surgeons should weigh technical variables such as ischemia of the bowel, patient factors, and surgeon and system factors, said Lynn M. O’Connor, MD, MPH, the chief of the Division of Colon and Rectal Surgery at Mercy Medical Center & St. Joseph Hospital, in Huntington, N,Y. “It’s really the context of the patient, as well as the surgeon’s experience that both will and should determine the choice of surgery,” she said. Evidence now supports primary anastomosis as the procedure of choice for stable patients with Hinchey III and IV classification. A 2019 meta-analysis that looked at the results of four trials comparing primary anastomosis with Hartmann’s procedure found that patients who underwent primary anastomosis were more likely to be stoma-free at 12 months after the initial surgery (risk ratio, 1.34; 95% CI, 1.16-1.54) and had a lower risk for complications following stoma reversal (Lancet Gastroenterol Hepatol 2019;4[8]:573-575). The authors also reported no differences in major postoperative complications or mortality at 12 months. However, primary anastomosis is rarely performed compared with Hartmann’s procedure. Of 2,729 patients in the United States who underwent emergency colectomy for diverticulitis between 2012 and 2016, 208 underwent a primary anastomosis (J Am Coll Surg 2019;229[1]:48-55). This year, the American Gastroenterological Association issued new guidelines on diverticulitis that highlighted the need for individualized treatment ■ (Gastroenterology 2021;160[3]:906-911.e1).
