Who Needs Elective Surgery for Recurrent Diverticulitis?

Patient population

Intervention

Comparator

Outcomes studied

Patients with recurrent diverticulitis

Resection

Expectant management

Risk of recurrence, morbidity, quality of life

We performed a systematic literature search with the aim of answering the following PICO (Patients, Intervention, Comparator, Outcome) question: “Who needs elective colon surgery for recurrent diverticulitis?” A targeted search of English language literature in MEDLINE, PubMed, EMBASE, and the Cochrane Database of Collected Reviews was performed. Key-word combinations using the Medical Subject Headings (MeSH) terms included “diverticulitis,” “diverticular,” “abscess,” “fistula,” “perforation,” “complicated,” “uncomplicated,” “colectomy,” “antibiotics,” “resection,” and “expectant management.” Directed searches of the embedded references from the primary articles were also performed in selected circumstances. Review papers were also searched for cross-references. We decided to include exclusively those papers written in English language with a date of publication within the last 15 years in order to produce updated recommendations. The grade of both literature reviewed and final recommendation was performed by using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system [12, 13]. The search was carried out in November 2015.

Results

Uncomplicated Diverticulitis

Historically the recommendation was to proceed with elective resection after the second episode of uncomplicated diverticulitis, due to the presumed morbidity and mortality of subsequent attacks [1]. However close scrutiny of the evidence fails to support this practice; therefore the decision to proceed with surgery should take into account other factors. When recommending elective colectomy vs. expectant management for uncomplicated diverticulitis, the following should be considered: risk of recurrence, risk of developing complicated diverticulitis, patient comorbidities, possibility of emergency surgery, and quality of life.

Recurrence rates for uncomplicated diverticulitis treated nonoperatively vary from 8 to 48 % and are gathered from studies with varying lengths of follow up (Tables 29.1 and 29.2). The two largest series include ~181,000 [14] and ~179,000 [15] patients, and report recurrence rates of 8.7 and 16.3 %, respectively. Patients with uncomplicated disease were less likely to recur than their complicated counterparts [14, 16]. Of patients who recur, most recur within 12 months of the index admission [16, 17]. Patients who dorecur have a greater chance of yet another episode as well. Overall recurrence rates in patients with uncomplicated diverticulitis are approximately 4.7 % after the index episode, according to one study [17]. Two multicenter retrospective trials demonstrated re-recurrence risk of 23.2 and 29 % in patients who had had at least one previous recurrence [14, 18].

Table 29.1

Diverticulitis outcomes

Study	N	Treatment	Results	Median F/U	QOE
Ho et al. [14] Retrospective multicenter	237,869 with diverticulitis (unspecified)	181,115/237,869 (76.1 %) treated non-surgically	8.7 % recurrence rate 23.2 % re-recurrence	Variable – NR	Moderate
Hall et al. [20] Retrospective	672 (index case of diverticulitis)	Non-surgical management	Overall recurrence 36 % Complicated recurrence 3.9 %	5 years	Low
Ambrosetti et al. [42] Prospective	542 patients with diverticulitis (unspecified)	405/542 (74.7 %) treated non-surgically	87/405 (21.2 %) had “bad outcome” (recurrence, abscess, stenosis, fistula) Risk factors for bad outcome: Age <50 Severity of disease as seen on CT	62 months	Low
Trenti et al. [16] Prospective	560 with diverticulitis (unspecified)	Non-surgical management	Recurrence observed in 14.8 %, Severe recurrence in 3.4 % Risk factors for recurrence: Chronic steroids Presence of abscess	67 months	Low
Rose et al. [15] Retrospective multicenter	210,268 with diverticulitis (unspecified)	179,569 (85 %) treated non-surgically	16.3 % recurrence rate 29.3 % rerecurrence Risk factors for recurrence: Complicated index episode Abscess Age <50	Variable – up to 15 years	Moderate
Anay and Elum [21] Retrospective multicenter	25,058 with acute diverticulitis (unspecified)	Non-surgical management = 20,136/25,058	19 % had recurrence 5.5 % required emergency operation at recurrence Risk factor for recurrences: Age <50 more likely to have recurrence (27 % vs 17 %)	Variable – NR	Moderate
Broderick-Villa et al. [18] Retrospective multicenter	3156 with acute diverticulitis (unspecified)	Non-surgical management = 2551/3156 (80.6 %)	Elective colectomy = 185/2551 Non-operative management = 2336/2551 13.3 % had recurrence Risk factors for recurrence: Younger patients Presence of comorbidities increased recurrence	8.9 years	Low
Klarenbeek et al. [40] Retrospective	291 patients	111 non op treatment 108 urgent/emergent surgery 72 elective surgery	Recurrence rate of 48 % in non op group Risk of recurrence: Complicated disease Immunosuppression Chronic renal failure Collagen vascular disease		Low
Holmer et al. [43] Prospective cohort	153 with acute diverticulitis (unspecified)	113 surgical resection 40 treated non-surgically	32 % of non surgically treated patients recurred 4 % of surgically treated patients recurred Risk factors for needing surgery: Perforated disease Recurrent episodes	32 months	Low
Li et al. [22] Retrospective multicenter	14,124 with acute diverticulitis (unspecified)	Non-operative management	9 % readmission for recurrence 1.9 % emergency surgery Risk factors for readmission/recurrence: Patients with initial complicated disease Age <50 likely to be readmitted	3.9 years	Moderate
Chapman et al. [25] Retrospective	150 with prior episodes of diverticulitis Group A – Pts with 1–2 previous episodes Group B – Pts with >2 previous episodes	Non-operative and operative management	Perforation occurred more frequently in Group A Fecal Diversion occurred more frequently in Group A When needing surgery: no difference in operative morbidity/mortality	NR	Low
Eglinton et al. [17] Retrospective	502 with diverticulitis Uncomplicated = 337 Complicated = 165	Non surgical management: Uncomplicated = 320/337 Complicated = 62/165	Uncomplicated recurrence = 23.4 % Complicated recurrence = 24 % Complicated diverticulitis more likely to undergo surgical resection	101 months	Low
Lamb and Kaiser [38] Systematic review/metanalysis	1051 patients – from 22 studies – diverticulitis with abscess formation	Urgent/emergent surgery (30 %) Elective surgery (36 %) Non-operative management (35 %)	Recurrence in patients waiting for elective resection = 39 % Recurrence in Non operative group = 18 % 28 % had no surgery and no recurrence	Variable	Moderate
Ambrosetti et al. [44] Prospective	73 patients with diverticular abscesses	Surgical and non-surgical management	22/45 (49 %) mesocolic abscesses & 8/28 (29 %) pelvic abscesses, successfully managed conservatively	43 months	Moderate
Kaiser et al. [45] Retrospective	511 patients with diverticulitis	Urgent, elective surgery Non-surgical management	Of 99 patients with abscess: 22 % required urgent operation 15 % underwent elective operation 41.2 % recurred after non operatively treatment	NR	Low
Chapman et al. [19] Retrospective	375 patients with complicated diverticulitis	Urgent, elective surgery Non surgical management	46 % had had previous episodes of diverticulitis 53 % was index episode of diverticulitis 6.5 % overall mortality rate Risk of morbidity and mortality: Older age Steroids/Immunodeficiency Diabetes Perforation on presentation	NR	Low
Nelson et al. [39] Retrospective	256 with complicated diverticulitis	99/256 (38.7 %) treated non-surgically	46/99 had recurrence 20/46 recurrences required sigmoid resection	14 years	Low
Gaertner et al. [41] Retrospective	218 patients treated with perc drain for complicated diverticulitis	32/218 (15 %) treated non-surgically	Recurrence rate was 42 % Risk Factors associated with recurrence: Abscess >5 cm	7.4 years	Low
Bridoux et al. [28] Retrospective	114 patients with Complicated diverticulitis	81/114 (71.1 %) treated non-surgically	7.4 % recurrence (median time of 12 months)	32 months	Low

Table 29.2

Quality of life

Study	N	Treatment	Results	Median F/U	QOE
Andeweg et al. [29] Systematic review/metanalysis	1858 patients – from 21 studies – uncomplicated diverticulitis	Elective surgical vs non surgical treatment of recurrent diverticulitis	Higher QOL scores in laparoscopic surgical group Lower GI symptoms in surgical group Less chronic abdominal pain in surgical group	NR	Moderate
van de Wall et al. [30] Retrospective cohort	105 patients with diverticulitis (unspecified)	Elective surgical resection	Elective resection: Improved QOL Reduced chronic abdominal pain Decreased discomfort from defecation	1 year	Low
Forgione et al. [32] Prospective cohort	46 patients with diverticulitis (unspecified)	Elective surgical resection (laparoscopic)	36/46 patients significantly had increased GIQLI scores Patients with lowest GIQLI scores increased benefited the most from surgery	1 year	Low
Levack et al. [35] Retrospective	249 patients with diverticulitis (unspecified)	Laparoscopic and open sigmoidectomy	24.8 % reported relevant fecal incontinence 19.6 % reported fecal urgency 20.8 % reported incomplete emptying Symptoms: risk factors Fecal incontenence: pre-op abscess, female Urgency: divertiting ostomy, female Incomplete emptying : post-op sepsis, female	NR	Low
Pasternak et al. [31] Retrospective	130 patients with diverticulitis (unspecified)	Elective surgical resection (laparoscopic)	83 % of patients with GIQOL >100 after surgery vs before (43 %) Mean QOL score of 114 after surgery vs before (95)	40 months	Low
Scarpa et al. [33] Retrospective	71 patients with uncomplicated diverticulitis	25/71 underwent resection 46/71 non-surgical management	Cleveland global QOL: No difference in total score No difference in symptom frequency Current quality of health was lower in surgical group	47 months	Low
Egger et al. [36] Retrospective	124 patients	68 patients – elective colectomy	25 % suffered persistent symptoms: constipation, abdominal distention, abdominal cramps, diarrhea Complicated vs uncomplicated were unrelated to symptomatology Technique (open vs laparoscopic) were unrelated to symptomatology	33 months	Low

Most patients presenting with complicated diverticulitis do so at their index admission for diverticulitis; 89 % of patients who die of the disease have no prior history of diverticulitis [19]. These data suggest that in most cases, the first episode is the worst episode. That is not to say that patients with uncomplicated diverticulitis can’t recur with a complicated form of the disease, and unequivocally will not require emergency surgery or a colostomy. However, rates of recurrent disease that is complicated range from 3 to 5 % in the literature [16, 17, 20]. Infact, most patients with a complicated or severe recurrence have had a previous episode of complicated/severe diverticulitis [16]. In addition, the risk of recurrent diverticulitis is positively associated with family history, length of colon involvement >5 cm [20], and presence of comorbidities [18]. Additionally risk of recurrence is associated with age <50 [14, 18, 21–23].

The risk of requiring an emergent colostomy after an initial episode of diverticulitis is strikingly low. A retrospective, multicenter study by Li et al. [22], described 14,124 patients treated nonoperatively, and found only 1.9 % of these patients subsequently had emergency surgery for perforation, with a median follow up of 3.9 years [22]. These findings are similar to another population-based study, which reviewed 25,058 patients where 20,136 patients were initially treated nonoperatively. While 19 % had a recurrence, only 5.5 % required a subsequent emergency colectomy [21]. The hazard ratio for emergency colectomy/colostomy was 2.2× higher in patients for each subsequent admission. According to this study, 18 patients would need to undergo elective colectomy to prevent one emergency surgery for recurrent diverticulitis [21].

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