The role of elective surgery following acute colonic diverticulitis
The surgical treatment following acute diverticulitis (DV) has been an ongoing subject of debate. During the first half of the 20th century, only complicated cases of acute DV were surgically treated. During the second half, some studies suggested that patients with recurrent episodes of uncomplicated DV had an increased risk of complicated disease, morbidity, and mortality, and, for that reason, surgery was indicated also for these patients. In 1995, the ASCRS recommended elective bowel resection after two episodes of uncomplicated acute DV (or one episode for patients younger than 50), or after one episode of complicated DV. Recent studies have questioned these three recommendations. First, although acute DV is particularly aggressive during its first episode, subsequent episodes tend to be significantly more benign and successfully manageable with non-operative treatment. Elective surgery decreases neither the likelihood of emergency surgery nor the overall mortality due to DV complications. Moreover, elective surgery is not risk free, and some patients still experience acute DV episodes post-operatively. Second, in patients under 50, the disease does not seem to be as aggressive as previously implied. The response to medical treatment and post-operative morbidity and mortality remain similar to older patients. Third, regarding episodes of complicated DV, whether surgery is always necessary after successful percutaneous abscess drainage has also been a matter of debate. International guidelines are consensual when indicating precocious surgical resection for patients chronically immunosuppressed, who have collagen-vascular disease, or chronic renal disease. While waiting for the results of the first randomised clinical trials comparing different treatment strategies for acute DV, the present paper reviews the debate regarding the indications for elective surgery.
MARTIN ST, STOCCHI L: New and emerging treatments for the prevention of recurrent diverticulitis. Clinical and Experimental Gastroenterology. 2011; 4 : 203-212.
VON RAHDEN BH, GERMER CT: Pathogenesis of colonic diverticular disease. Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie. 2012; 397(7) :1025-1033.
YEO CJ MJ, MCFADDEN DW, PEMBERTON JH, PETERS JH: Shackelford's Surgery of the Alimentary Tract. 7th ed: Elsevier; 2013.
ANGRIMAN I, SCARPA M, RUFFOLO C: Health related quality of life after surgery for colonic diverticular disease. World Journal of Gastroenterology : WJG. 2010;16(32) : 4013-4028.
BORDEIANOU L, HODIN R: Controversies in the surgical management of sigmoid diverticulitis. Journal of Gastrointestinal Surgery : Official Journal of the Society for Surgery of the Alimentary Tract. 2007; 11(4) : 542-548.
WASVARY H, TURFAH F, KADRO O: Same hospitalization resection for acute diverticulitis. Am Surg. 1999 (65) : 632–635.
RAFFERTY J, SHELLITO P, HYMAN NH, BUIE WD, STANDARDS COMMITTEE OF AMERICAN SOCIETY OF C, RECTAL S: Practice parameters for sigmoid diverticulitis. Diseases of the Colon and Rectum. 2006; 49(7) : 939-944.
STOCCHI L: Current indications and role of surgery in the management of sigmoid diverticulitis. World Journal of Gastroenterology : WJG. 2010; 16(7) : 804-817.
AYDIN HN, REMZI FH: Diverticulitis: when and how to operate? Digestive and Liver Disease : Official Journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2004; 36(7) : 435-445.
AMBROSETTI P, GERVAZ P: Laparoscopic elective sigmoidectomy for diverticular disease: a plea for standardization of the procedure. Colorectal Disease : The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2014; 16(2) : 90-94.
CIROCCHI R, FARINELLA E, TRASTULLI S, SCIANNAMEO F, AUDISIO RA: Elective sigmoid colectomy for diverticular disease. Laparoscopic vs open surgery: a systematic review. Colorectal Disease : The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2012; 14(6) : 671-683.
SCOZZARI G, AREZZO A, MORINO M: Enterovesical fistulas: diagnosis and management. Techniques in Coloproctology. 2010; 14(4) : 293-300.
SWANK HA, VERMEULEN J, LANGE JF, MULDER IM, VAN DER HOEVEN JA, STASSEN LP, ET AL: The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surgery. 2010; 10 : 29.
THORNELL A, ANGENETE E, GONZALES E, HEATH J, JESS P, LACKBERG Z, ET AL: Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial. Trials. 2011; 12 : 186.
VAN DE WALL BJ, DRAAISMA WA, CONSTEN EC, VAN DER GRAAF Y, OTTEN MH, DE WIT GA, ET AL: DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative treatment. A multicenter randomised clinical trial. BMC Surgery. 2010; 10 : 25.
MOORE FA, CATENA F, MOORE EE, LEPPANIEMI A, PEITZMANN AB: Position paper: management of perforated sigmoid diverticulitis. World Journal of Emergency Surgery : WJES. 2013; 8(1) : 55.
DONALD JM: The surgical management of diverticulitis of the colon. Annals of Surgery. 1951; 133(5) : 708-718.
WELCH CE, ALLEN AW, DONALDSON GA: An appraisal of resection of the colon for diverticulitis of the sigmoid. Annals of Surgery. 1953; 138(3) : 332-343.
MOORE RM, KIRKSEY OT, JR. One-stage resection in selected cases of sigmoid diverticulitis. Annals of Surgery. 1954; 139(6) : 826-832.
CHAPMAN JR, DOZOIS EJ, WOLFF BG, GULLERUD RE, LARSON DR: Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?
Annals of surgery. 2006; 243(6) : 876-830; discussion 80-3.
COLLINS D, WINTER DC: Elective resection for diverticular disease: an evidence-based review. World Journal of Surgery. 2008 ; 32(11) : 2429-2433.
PARKS TG: Natural history of diverticular disease of the colon. A review of 521 cases. British Medical Journal. 1969; 4(5684) : 639-642.
JANES S, MEAGHER A, FRIZELLE FA: Elective surgery after acute diverticulitis. The British Journal of Surgery. 2005; 92(2) : 133-142.
STOLLMAN NH, RASKIN JB: Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. The American Journal of Gastroenterology. 1999; 94(11) : 3110-3121.
KOHLER L, SAUERLAND S, NEUGEBAUER E: Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surgical endoscopy. 1999; 13(4) : 430-436.
SALEM L, ANAYA DA, FLUM DR: Temporal changes in the management of diverticulitis. The Journal of Surgical Research. 2005; 124(2) : 318-323.
ANDEWEG C, PETERS J, BLEICHRODT R, VAN GOOR H: Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease. World journal of surgery. 2008; 32(7) : 1501-1506.
HART AR, KENNEDY HJ, STEBBINGS WS, DAY NE: How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. European Journal of Gastroenterology & Hepatology. 2000; 12(6) : 661-665.
Pittet O, Kotzampassakis N, Schmidt S, Denys A, Demartines N, Calmes JM. Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis World Journal of Surgery. 2009; 33(3) : 547-552.
SOMASEKAR K, FOSTER ME, HARAY PN: The natural history diverticular disease: is there a role for elective colectomy? Journal of the Royal College of Surgeons of Edinburgh. 2002; 47(2) : 481-484.
KLARENBEEK BR, SAMUELS M, VAN DER WAL MA, VAN DER PEET DL, MEIJERINK WJ, CUESTA MA: Indications for elective sigmoid resection in diverticular disease. Annals of Surgery. 2010; 251 (4) : 670-674.
CHAPMAN J, DAVIES M, WOLFF B, DOZOIS E, TESSIER D, HARRINGTON J, ET AL: Complicated diverticulitis: is it time to rethink the rules? Annals of Surgery. 2005; 242(4) : 576-581; discussion 81-3.
MAKELA JT, KIVINIEMI HO, LAITINEN ST: Spectrum of disease and outcome among patients with acute diverticulitis. Digestive Surgery. 2010; 27(3) : 190-196.
ANDEWEG CS, MULDER IM, FELT-BERSMA RJ, VERBON A, VAN DER WILT GJ, VAN GOOR H, ET AL: Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Digestive Surgery. 2013; 30(4-6) : 278-292.
RITZ JP, LEHMANN KS, STROUX A, BUHR HJ, HOLMER C: Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients? Journal of Gastrointestinal Surgery : The Official Journal of the Society for Surgery of the Alimentary Tract. 2011; 15(4) : 667-674.
BINDA GA, AREZZO A, SERVENTI A, BONELLI L, ITALIAN STUDY GROUP ON COMPLICATED D, FACCHINI M, ET AL: Multicentre observational study of the natural history of left-sided acute diverticulitis. The British Journal of Surgery. 2012; 99(2) : 276-285.
CHAUTEMS RC, AMBROSETTI P, LUDWIG A, MERMILLOD B, MOREL P, SORAVIA C: Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Diseases of the Colon and Rectum. 2002; 45(7) : 962-966.
ANAYA DA, FLUM DR: Risk of emergency colectomy and colostomy in patients with diverticular disease. Archives of Surgery. 2005; 140(7) : 681-685.
BRODERICK-VILLA G, BURCHETTE RJ, COLLINS JC, ABBAS MA, HAIGH PI: Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Archives of Surgery. 2005; 140(6) : 576-581; discussion 81-3.
PEPPAS G, BLIZIOTIS IA, OIKONOMAKI D, FALAGAS ME: Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence. Journal of Gastroenterology and Hepatology. 2007; 22(9) : 1360-1368.
SALEM L, VEENSTRA DL, SULLIVAN SD, FLUM DR: The timing of elective colectomy in diverticulitis: a decision analysis. Journal of the American College of Surgeons. 2004; 199(6) : 904-912.
RICHARDS RJ, HAMMITT JK: Timing of prophylactic surgery in prevention of diverticulitis recurrence: a cost-effectiveness analysis. Digestive Diseases and Sciences. 2002; 47(9) : 1903-1908.
FORGIONE A, LEROY J, CAHILL RA, BAILEY C, SIMONE M, MUTTER D, ET AL: Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Annals of Surgery. 2009; 249(2) : 218-224.
KATZ LH, GUY DD, LAHAT A, GAFTER-GVILI A, BAR-MEIR S: Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis. Journal of gastroenterology and hepatology. 2013; 28(8) : 1274-1281.
FARIA GR, ALMEIDA AB, MOREIRA H, PINTO-DE-SOUSA J, CORREIA-DA-SILVA P, PIMENTA AP: Acute diverticulitis in younger patients: any rationale for a different approach? World Journal of Gastroenterology : WJG. 2011; 17(2) : 207-212.
GUZZO J, HYMAN N: Diverticulitis in young patients: is resection after a single attack always warranted? Diseases of the Colon and Rectum. 2004; 47(7): 1187 1190; discussion 90-1.
ETZIONI DA, MACK TM, BEART RW, JR., KAISER AM: Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Annals of Surgery. 2009; 249(2) : 210-217.
EGLINTON T, NGUYEN T, RANIGA S, DIXON L, DOBBS B, FRIZELLE FA: Patterns of recurrence in patients with acute diverticulitis. The British Journal of Surgery. 2010; 97(6) : 952-957.
JANES S, MEAGHER A, FARAGHER IG, SHEDDA S, FRIZELLE FA: The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature. Diseases of the Colon and Rectum. 2009; 52(5) : 1008-1016.
UNLU C, VAN DE WALL BJ, GERHARDS MF, WIEZER M, DRAAISMA WA, CONSTEN EC, ET AL: Influence of age on clinical outcome of acute diverticulitis. Journal of Gastrointestinal Surgery : THe Official Journal of the Society for Surgery of the Alimentary Tract. 2013; 17(9) : 1651-1656.
FINGERHUT A, VEYRIE N: Complicated diverticular disease: the changing paradigm for treatment. Revista do Colegio Brasileiro de Cirurgioes. 2012; 39(4) : 322 -327.
SOUMIAN S, THOMAS S, MOHAN PP, KHAN N, KHAN Z, RAJU T: Management of Hinchey II diverticulitis. World Journal of Gastroenterology : WJG. 2008; 14(47):7163-7169.
BACHMANN K, KRAUSE G, RAWNAQ T, TOMKOTTER L, VASHIST Y, SHAHMIRI S, ET AL: Impact of early or delayed elective resection in complicated diverticulitis. World Journal of Gastroenterology : WJG. 2011; 17(48) : 5274-5279.
MCCAFFERTY MH, ROTH L, JORDEN J: Current management of diverticulitis. The American Surgeon. 2008; 74(11) : 1041-1049.
AMBROSETTI P, CHAUTEMS R, SORAVIA C, PEIRIS-WASER N, TERRIER F: Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Diseases of the Colon and Rectum. 2005; 48(4) : 787-791.
PSARRAS K, SYMEONIDIS NG, PAVLIDIS ET, MICHA A, BALTATZIS ME, LALOUNTAS MA, ET AL: Current management of diverticular disease complications. Techniques in Coloproctology. 2011; 15 Suppl 1 : S9-12.
WOODS RJ, LAVERY IC, FAZIO VW, JAGELMAN DG, WEAKLEY FL: Internal fistulas in diverticular disease. Diseases of the Colon and Rectum. 1988; 31(8) : 591-596.
MCDERMOTT FD, COLLINS D, HEENEY A, WINTER DC: Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. The British Journal of Surgery. 2014; 101(1) : e90-99.