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Surgery for Diverticulitis: Who, When and How Still Up for Debate

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become increasingly complex, said moderator Jason Hall, MD, MPH, an associate professor of surgery and the co-director of the Dempsey Center for Digestive Disorders at Boston University. “(Now) we often spend long, long minutes in the office, reviewing lots of options for management with our patients.”

For patients who are not acutely ill but have had at least one episode of uncomplicated diverticulitis, surgeons should use patient-centered outcomes when deciding whether to operate, said Sean Langenfeld, MD, an associate professor and the chief of colon and rectal surgery at the University of Nebraska Medical Center, in Omaha. “In 2021, when you think about good reasons to operate, you can summarize it in three words—quality of life,” he said.

Elective sigmoid colectomies should be performed to improve quality of life rather than to prevent a future hypothetical emergency, Dr. Langenfeld said. Quality of life should take priority over traditional objeconal objective metrics such as the number of attacks ttacks or CT findings, he added.

The standard of care for diverticculitis patients has changed markedly over the past two decades. In the past, surgery was recommended for anyone who had a second attack of diverticulitis, or was younger than 50 years of age or immunocompromised at the first episode. In addition, for patients s who did not have surgery, antibiottics were given as standard, reflecting cting the belief that diverticulitis resultted from microperforation and infection. However, in 2014, the ASCRS ‘Diverticulitis has a very changed its guideline on surgery for wide spectrum of disease diverticulitis, saying the decision to operate should be individualized to type and severity, and the patient and not based on the there is no one single rule number of attacks. Recommendations are still evolv- in terms of treatment.’ ing, surgeons said during the session —Dana M. Hayden, MD, MPH titled “Management of Diverticulitis. Is There Anything We Were Taught That Is True?”

Today, emerging evidence suggests that diverticulitis arises from chronic inflammation of the gut and not infection (Gastroenterology 2019;156[5]:1282-1298.e1). Moreover, recurrences after uncomplicated diverticulitis are less frequent than previously estimated: Nonoperative management of acute uncomplicated diverticulitis is successful in more than 95% of patients, Dr. Langenfeld said. This suggests that diverticulitis is not a progressive disease, he noted.

As understanding of diverticulitis evolved, surgery became reserved for a more selected group of patients. But exactly who and when and how are still up for debate. Uncomplicated Diverticulitis: What to Do

When You Don’t Operate

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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.

Patients who have more frequent attacks or disabling pain with attacks, or struggle with finances, work or social life due to diverticulitis may benefit from surgery, he said, adding that some patients want surgery because they miss too many days of work from their disease or receive repeated hospital bills related to this condition, he said. He advised surgeons to take these quality-oflife issues into account. The decision to operate is “very much individualized based on the patient’s quality of life and priorities,” he said.

“And when the time comes, sigmoid colectomy works,” Dr. Langenfeld added, noting that the risk for recurrent diverticulitis after colectomy is between 4% and 6%. Studies show patients’ quality of life improves with surgery versus conservative management (Ann Surg 2019;269[4]:612-620).

An ongoing randomized trial may yield more definitive answers about the value of surgery in this population. The COSMID study is a multicenter, American trial designed to compare the best medical care and sigmoid colectomy for patients who are asymptomatic after recurrent uncomplicated diverticulitis or those who experience ongoing symptoms for more than three months after an index attack. “This is a fundamentally key question for us as colorectal surgeons as we see so many patients like this,” said co-principal investigator Thomas E. Read, MD, a professor and the chief of gastrointestinal surgery at the University of Florida College of Medicine, in Gainesville. Investigators plan to enroll 500 patients and assign them to surgery or medical management with a variety of tools including diet and exercise, fiber supplementation, probiotics and rifamycin/mesalazine, said principal investigator David Flum, MD, MPH, a professor of surgery and the director of the University of Washington’s Surgical Outcomes Research Center, in Seattle. All patients will complete the GIQLI at randomization and again at six, nine and 12 months after treatment.

Investigators are looking to include patients treated at large and small hospitals, in rural and urban environments, and a mix of academic and community practices. Surgeons interested in participating are asked to contact one of the investigators, Dr. Flum said.

Fifteen hospitals in the United States are currently enrolling patients. The first results from the trial are expected after 2024.

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). ■