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COMMENTS: SURGERY

Article review: Left-sided acute diverticulitis

Abstract

Background. The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD.

Methods. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up.

Results. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32.6%) underwent emergency surgery at accrual. After a mean follow-up of 10.7 years, rates of recurrence (17.2% vs. 5.8%; P < 0.001) and emergency surgery (6.9% vs. 1.3%; P = 0.021) were higher in medically treated patients than in those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1% and disease-related mortality was zero in this group. The disease-related mortality rate was 0.6% among patients who had surgical treatment.

Conclusion. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Comment

Acute diverticulitis is the most common complication of colonic diverticular and affects approximately 25% of all patients with this disorder. About a third of these patients will experience a recurrence, and about 10% need emergency surgery owing to life-threatening complications (perforation, colonic obstruction, bleeding).

In the late 1990s some guidelines recommended elective colectomy after a second episode of acute diverticulitis, but in 2006 the American Society of Colon and Rectal Surgeons (ASCRS) suggested a more cautious procedure.

Most previous studies have been retrospective, or recruited only small numbers of patients. This study recruited 407 patients retrospectively and 336 patients prospectively.

This study group found no association between the risk for emergency surgery, sex, age at entry and number of previous acute episodes.

Limitations of the study include lack of distinction of treatment modality based on severity of disease, missing data for about one-third of the participants and analysis of only those patients hospitalized for diverticulitis.

Although patients in the medically treated group were more likely to suffer from chronic symptoms than the surgically treated patients, the difference was less than 6%.

The study group also described that the rate of recurrent acute diverticulitis was low even among the medically treated patients. Although the risk was higher among young patients, the study failed to show a time interval in which the recurrences were most likely to occur.

The study group also found that a long history of diverticulitis or an increasing number of acute episodes were not necessarily associated with a higher risk of serious complications from surgical treatment.

This paper is in accordance with previous publications showing that the ‘old paradigms’ regarding the indication for surgery (number of episodes, prevention of perforation by elective surgery and young age) need to be questioned. The introduction of new antibiotic regimens with action limited to the colon (without systemic absorption) as well anti-inflammatory agents known to be effective in the treatment of inflammatory bowel disease have influenced our approach to symptomatic diverticulosis.

In accordance with this, the authors of this study conclude that ‘the natural history of conservatively treated [acute diverticulitis] seemed quite benign.’

Therefore, the decision for elective surgery seems to be more influenced by quality of life on a case- to-case basis today.

Brigitte Kovanyi-Holzer

Associate Professor of Surgery

Vienna Medical School

Email: Brigitte.Holzer@wienkav.at


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