American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Following the evidence in diverticulitis treatment

OCTOBER 23, 2017
Clinical Congress Daily Highlights, Monday First Edition

Treatment of diverticulitis is complex, in part because it requires consideration of multiple clinical factors and the evidence supporting various approaches remains limited. A Monday morning panel presented data on various techniques, with the goal of advancing evidence-based methods of treating and managing the condition.

John Migaly, MD, FACS, Duke University Medical Center, Durham, NC, described the increasing interest in laparoscopic lavage instead of a traditional Hartmann procedure or primary re-anastomosis. Although technically simpler, laparoscopic lavage was not supported by several clinical trials and meta-analyses, he reported. In fact, this procedure may be associated with increased rates of total reoperations and subsequent percutaneous drainage.

Other studies have sought to identify predictors of success or failure for percutaneous abscess drainage, the initial procedure of choice for most abdominal abscesses. David J. Maron, MD, MBA, FACS, FASCRS, vice chairman, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, showed that the presence of immunosuppression or renal insufficiency are associated with failure from percutaneous drainage or a need for non-elective colectomy. While he concluded that there may not yet be answers to “watch and wait versus operate,” these data may help surgeons make more informed treatment decisions.

The use of endoluminal stents, especially as a bridge to surgery in benign colorectal obstructions, is another area of limited study. Elisabeth (Lisa) C. McLemore, MD, FACS, FASCRS, chief, Colon and Rectal Surgery, Los Angeles Medical Center, Southern California Permanente Medical Group, presented contexts in which endoluminal stents result in favorable outcomes, such as shorter stricture length and uncovered stents. She also identified new directions with biodegradable stents that may provide additional clinical advantages in the future.

More data are needed to define the clinical categories of diverticulitis, which may extend beyond the traditional and perhaps simplistic classifications of “complicated” and “uncomplicated.” Ron G. Landmann, MD, FACS, FASCRS, Mayo Clinic, Jacksonville, FL, described data on smoldering diverticulitis, which represents a more complicated form of uncomplicated diverticulitis and may warrant early surgical intervention.

Larger and more robust studies are needed to better understand the efficacy of various techniques across different contexts, said Tracy L. Hull, MD, FACS, The Cleveland Clinic Foundation, Cleveland, OH. Treatment decisions need to consider patient factors, intraoperative factors and surgeon preference. The presenters collectively highlighted the importance of evidence-based stewardship as the field continues to evolve and the clinical evidence grows, as well as case-by-case evaluation rather than rigid surgical protocols. As Dr. McLemore advised, “Use your experience as well as the literature to guide and do the best thing for the patient, because the disease is so variable.”

Additional Information:
The Panel Session, Controversies in the Management of Complicated Diverticulitis, was held October 23, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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