clinical outcomes of complicated diverticulitis managed nonoperatively

R. Scott Nelson D.O , B. Mark Ewing B.S., Timothy J. Wengert M.D. and Alan G. Thorson M.D.

Clinical outcomes of complicated diverticulitis managed

nonoperativelyThe Southwestern Surgical Congress

December 2008 (Vol. 196, Issue 6, Pages 969-974)1

• The incidence of diverticulitis within the United States is increasing, This is based in part on technology that is able to provide a noninvasive diagnosis

• Younger patients typically not thought of having this disease process are now more frequently being diagnosed

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• This technology, specifically computed tomography (CT) scans, is playing a more integral part in the diagnosis and management of the disease .

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• Frequently, a history of diverticulosis with the onset of typical symptomatology has been used to diagnosis a flare of diverticulitis without confirmatory study

• CT scanning has redefined the diagnosis of diverticulitis by its ability to visualize and distinguish between the different variants of this disease process

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• Acute diverticulitis:– Uncomplicated :

• evidence of colonic wall thickening • pericolonic inflammatory changes such as fat stranding

– Complicated :• Abscess• Fistula• Obstruction• localized or free perforation

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• Radiographic findings, in conjunction with the patient's history, comorbidities, and physical examination are now frequently used to establish whether an operation or nonoperative management should be prescribed.

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• Historically, recommendations for resection of uncomplicated disease were based on– 2 previous episodes of diverticulitis or– 1 episode if the patient was less than 50 years of

age

• Newer data and recommendations have called for a revision of the practice of aggressive surgical resection in patients with uncomplicated disease, despite recurrence or age.

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• The basis of these arguments is that a majority of patients do not seem to progress from uncomplicated to complicated disease over time.

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• Complicated diverticulitis is considered an indication for elective operation.

• Patients with an abscess or localized perforation in particular have been treated with antibiotics, and percutaneous drainage if indicated.

• Following this course of action they are typically scheduled for elective resection.

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• However, our understanding of the natural history of diverticulitis is changing as our ability to visualize the disease has changed.

• The aim of this study was to assess the outcomes of a group of individuals with complicated findings on CT scan that had been followed without an operation.

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Materials and Methods

• Retrospective study• 14-year period (1993 - 2006)• complicated diverticulitis (CT scan)

– Patient demographics (age and sex) – Operation performed– CT findings– Recurrence

• Patients without CT scan evidence of complicated diverticular disease were not included in the study.

• . P values ≤.05 were considered statistically significant.

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Results

• 256 patients (142 males).• mean age of the population was 63 years

(range 22–91)• 79% of the patients under the age of 70• 99 (38.6%) were initially managed

nonoperatively

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Age yr

21–30 31–40 41–50 51–60 61–70 71–80 81–90 91+

Operative group

2 24 38 19 38 24 9 3

Nonoperative group

3 8 11 27 33 12 5 0

Total group 5 32 49 46 71 36 14 3

Age distribution of population per decade

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256 Complicated Diverticulitis

99Followed

157Operated

46Recurrence

82Anterior

Resection

75Hartmann20

Operation

1Hartmann

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• Patients younger than age 50 were evaluated against those older than 50 years of age to determine if they were at risk of:– requiring an emergent operation, or– having more recurrent disease.

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86 ( < 50 Y )

22 ( non – operative )

64( Operative )

4 (18.2 %)Surgery

77 (> 50 Y )

Non-operative

16 (20.8 %)Surgery

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157Operated

82Anterior

Resection

75Hartmann

27 (42% )< 50 Y

48 ( 51.6 % )> 50Y

patients less than 50 years of age had fewer emergency operations17

• When followed without surgery, younger patients did not appear to be at higher risk for recurrent attacks compared with older patients.

• 11 of the 22 patients (50%) younger than 50 years of age had at least 1 recurrence, whereas 31 of the 77 patients (40.3%) older than 50 had at least 1 recurrence (P = .6453).

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• Thus, there was no difference between recurrence or need for emergency operation based on age.

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Reasons for nonoperative treatment

patient response to medical management 32no referral to a surgeon by the medical physicians 47patient's refusal of an operation 9patient being deemed too ill for an operation 11

total 99

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Initial CT scan findings for both groups

CT scan findings

Nonoperative group (n = 99)

Operative group (n = 156) P value

Abscess 56 55 .0011

Localized perforation 35 21 .0006

Free perforation 1 66 <.0001†

Fistula 2 13 .0713

Phlegmon 5 0 SD

Obstruction 0 2 SD

SD = sample deficiency.

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99 ( all recived Antibiotics )

11percutaneous drain placements

1Hartmann procedure

for obstruction

1elective sigmoid

resection

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Non Operative Group

• Mean follow-up of these 99 nonoperatively treated patients was 76.3 months.

• 75 recurrent episodes requiring some form of treatment occurred in 46 patients (46.4%).

• Of these recurrent episodes:– 62 were uncomplicated – 13 were complicated.

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• 20 of the 99 patients ultimately had an operation, greater than 6 months out from their first complicated attack, with 1 patient requiring the Hartmann procedure .

• These 20 patients had significantly more recurrent episodes of diverticulitis

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• Of the patients undergoing an operation within 6 months of their complicated episode of diverticulitis:– 82 (52.2%) had a sigmoid resection – 75 (47.7%) underwent a Hartmann procedure

• 19 CT-guided percutaneous drains were placed in this group– 17 were later treated with a sigmoid resection – 2 failed drainage, requiring a Hartmann

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Comments

• While diverticular disease appears to be increasing in incidence, less than 1% of patients will need to be managed operatively

• Different classification systems have been devised to better define the different presentations of diverticular disease.

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• Hinchey described his well-known 4 stages of complicated diverticulitis found at laparotomy

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• More recently, Ambrossetti et al have described a classification system for diverticulitis based on CT scan criteria.

• 2 categories :– Complicated :

• Abscess• extraluminal air• extraluminal contrast

– Uncomplicated

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• The American Society of Colon and Rectal Surgeons (ASCRS) consensus statement includes obstruction and fistula

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• In a recent study by Chapman et al :– morbidity and mortality rates were not

significantly different between patients who suffered multiple attacks (>3) versus those with only 1 or 2 attacks.

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• Haglund et al :– monitored 372 patients for 12 years and

concluded that patients with complicated diverticulitis usually presented with perforation, on their first episode and not later on, even with multiple recurrences.

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• Anaya et al:

• large population-based study of more than 20,000 patients admitted with nonoperatively managed diverticulitis, found that only 5.5% progressed to require an emergency colectomy or colostomy.

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• Our data similarly demonstrate that patients with complicated disease do not have a significant risk for returning on an emergency basis with perforation and need for colostomy.

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• Based on these findings, patients with diverticular disease who have had a complicated finding on CT scan should be informed that the risk of recurrence requiring fecal diversion is low.

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• However, the risk of recurrent disease is quite high and should be considered along with the patient's desires, lifestyle considerations, work requirements, and other comorbidities as a course of therapy is chosen.

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Conclusions• risk of perforation and need for colostomy after a

medically treated complicated episode of diverticulitis were extremely low.

• However, recurrence of disease within our mean follow-up period of 6 years was almost 50%.

• The patient's comorbidities, response to treatment, age, and their desires, as well as type of operation available, should all play a role when designing the treatment algorithm for this disease.

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Thank You

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