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

Clearing up controversy over diverticulitis management

OCTOBER 22, 2018
Clinical Congress Daily Highlights, Monday First Edition


Diverticulitis was first described in the early 1700s by French surgeon Alexis Littré. Yet despite its long history, the guidelines around its management continue to evolve. Monday’s panel session convened five speakers to discuss the treatment of diverticulitis, which is increasing in incidence and leads to nearly $2.4 billion in direct health care costs each year in the United States.

Valentine N. Nfonsam, MD, FACS, Department of Surgery, The University of Arizona College of Medicine Tucson, AZ, opened the session by summarizing the evolution of clinical guidelines, especially around the commonly invoked paradigm of “two strikes and you’re out” – that is, surgical resection after two attacks of uncomplicated diverticulitis. Indeed, early guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Gastroenterology (ACG) agreed that elective resection is indicated after two attacks of uncomplicated diverticulitis.

Over time however, this treatment paradigm began to shift, especially with the publication of a 2005 review that found no evidence to support the recommendation of elective surgery following two attacks. Today, the most recent guidelines from the ASCRS, ACG and the American Gastroenterological Association (AGA) support the lack of evidence of increased risk for morbidity and mortality with two or more episodes, and emphasize the importance of individualizing treatment in such cases based on other patient factors.

Whether and when to operate

Once surgery is warranted, surgeons can also ensure that certain measures are put in place to optimize both the procedure itself as well as outcomes. Alexander T. Hawkins, MD, MPH, Vanderbilt University Medical Center, Nashville, TN, outlined several areas that should be taken into account and potentially managed prior to surgery, including obesity, medical comorbidities, frailty, immunosuppressed/transplant patients and smoking status. For example, smoking status is linked to a 30 percent increase in morbidity and a 50 percent increase in mortality; patients should be encouraged to stop smoking at least eight weeks prior to surgery.

The clinical management of diverticulitis has remained controversial partly because many clinical studies have been at odds with each other. Amy Lightner, MD, Mayo Clinic, Rochester, MN, discussed whether laparoscopic lavage should be used in complicated diverticulitis. She summarized findings from three major clinical trials – LOLA, SCANDIV and DILALA – which found inconsistent results. She noted that, “as with most decisions in surgery that we make, it comes down to patient selection, the physician experience with laparoscopic lavage and also the patient expectations.”

Additionally, uncertainty remains over whether nonoperative management is acceptable and safe. Michelle Cowan, MD, Department of Surgery, University of Colorado School of Medicine, Denver, CO, acknowledged that while the data are not always conclusive, this only further underscores the need to assess each patient individually: “While the data don’t give us an obvious answer of what to do, it allows us to talk to our patient and individualize their care.”

The value of experience

As the data continue to emerge, improving upon surgical procedures and outcomes can be guided by experience. Karim Alavi, MD, MPH, FACS, FASCRS, UMass Memorial Medical Center, Worcester, MA, emphasized the enormous difficulty of a colostomy closure after a Hartmann’s procedure. He noted that each of the multiple phases in this procedure constitutes a major surgical procedure in itself. Dr. Alavi provided a “top ten” list of recommendations based on his experience to help minimize complications and ease the procedure for both the surgeon and the patient.

Ultimately, the complex nature of diverticulitis and the patients who experience this condition necessitates a tailored approach, the speakers said, and additional prospective studies are needed to clarify this evolving discussion.

Additional Information

Program, webcast, and audio information is available online at facs.org/clincon2018.

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