Surgeons were encouraged to “follow the evidence” when managing patients with uncomplicated diverticulitis during the well-attended Clinical Congress 2023 session: Diverticulitis: The Widening Gap Between Data and Practice.
Nonantibiotic management of uncomplicated diverticulitis—a treatment option typically used in Europe—was a key topic.
“Let’s begin by asking ourselves how and why antibiotic therapy became the default management of uncomplicated diverticulitis in the first place,” said Marylise Boutros, MD, FACS, regional research director of the Digestive Disease and Surgery Institute at the Cleveland Clinic Florida in Weston. “Because just like in a court of law, when it comes to diverticulitis, antibiotics are presumed innocent until proven guilty rather than the reverse, which makes it a particularly difficult uphill battle for anyone challenging the century-old dogma.”
Dr. Boutros noted that clinicians’ understanding of diverticulitis and its pathogenesis has evolved. “The proposed pathophysiology of acute diverticulitis is a complex interaction between diet, lifestyle factors, genetics, chronic systemic inflammation, and the microbiome…and as this research continued to emerge, some began to question the routine administration of antibiotics in the absence of perforation.”
She explained that dissemination of evidence-based information is essential for widespread adoption of nonantibiotic treatment of this disease, including education focused on both the physician and the patient.
“Addressing this issue requires not necessarily learning new knowledge, but rather unlearning old and outmoded knowledge,” she said, noting that unlearning needs to occur at the individual and organizational levels.
In addition to nonantibiotic management of uncomplicated diverticulitis, panelists discussed the transition of the Hartmann’s procedure into a potential “last resort” approach, the treatment of diverticulitis in the immunocompromised patient, and racial disparity in the treatment of acute diverticulitis.
Dana M. Hayden, MD, FACS, chair of the Division of Colon and Rectal Surgery at the University of Wisconsin School of Medicine and Public Health in Madison, said that the prevalence of diverticulitis in immunosuppressed patients is higher than in the general population (1% of admissions versus 0.02%), adding that the “signs and symptoms present differently in these patients and may not reflect the severity of the disease that is happening in the patient’s abdomen.” Specifically, typical signs of infection like fever and tachycardia can be absent or highly attenuated in these patients.
Dr. Hayden presented an overview of treating diverticulitis in immunosuppressed patient populations, such as those with diabetes, renal and liver failure, lung and cardiac transplant patients, and she described possible complications and treatment options for each.
While nearly 3 million Americans are diagnosed with diverticulitis each year, treatment inequities for a significant number of these patients persist, according to Hanjoo Lee, MD, FACS, a colon and rectal surgeon from the David Geffen School of Medicine at the University of California, Los Angeles.
Dr. Lee cited several studies that revealed higher rates of morbidity and mortality for racial minorities with diverticulitis and other forms of colorectal disease, including a study by Schneider and colleagues that showed among Medicare patients with diverticulitis from 2004 to 2007, Black patients had a 26% greater risk of urgent/emergency admissions than White patients.
According to Dr. Lee, Black patients with diverticulitis may have limited access to quality healthcare and disease prevention strategies due to either lack of insurance and/or misguided distrust of the healthcare system. As a result, these patients often present with higher baseline risk, which negatively impacts their postoperative recovery. He called for “collaborative efforts between government agencies and private enterprises” to mitigate inequities in care, particularly in urban, underserved communities.
On-demand viewing of the session is available on the virtual meeting platform for Clinical Congress registrants through May 1, 2024.
