Surgery may be best for older, complex patients with diverticulitis

Last Updated: 2015-02-19

By Anne Harding

NEW YORK (Reuters Health) - Colectomy should be "strongly considered" for emergent diverticulitis patients having a first episode of the disease who are older than 50 or have complications such as perforation, according to the authors of a longitudinal study.

These patients have a far greater risk of death or serious complications upon recurrence, Dr. John Rose, of the University of California San Diego School of Medicine in La Jolla, and colleagues found in their analysis, which included the largest cohort of diverticulitis patients yet studied.

While most patients will get better with medical management and don't need surgery after their first admission to the hospital for emergent diverticulitis, up to 30% will have recurrence of the disease, Dr. Rose and his team note in their report, published online February 14 in the Annals of Surgery. Practice guidelines recommend elective colectomy after two episodes of uncomplicated diverticulitis or one episode of complicated diverticulitis, the authors note.

"The idea was if a patient comes in with diverticulitis and doesn't have a complex presentation, meaning something more than just pain, you could manage it conservatively with antibiotics," Dr. Rose told Reuters Health in a telephone interview.

In 2006, the American Society of Colon and Rectal Surgery modified its guidelines to recommend that doctors evaluate whether a patient is a candidate for surgery on a case-by-case basis.

Little is known about long-term outcomes for diverticulitis patients, Dr. Rose and his colleagues add.

"A lot of our practice guidelines are based on really small data from a really long time ago," Dr. David Chang, another study author and a senior health researcher and analyst at UCSD, told Reuters Health in a telephone interview.

To address these evidence gaps, the researchers looked at data from the California Office of Statewide Health Planning and Development on 210,268 patients admitted to the hospital for emergent diverticulitis between 1995 and 2009. Patients were followed for up to 15 years for recurrence.

Eighty-five percent of patients were managed medically at their first presentation to the emergency department. Among these patients, 16.3% had a recurrence.

Multivariate analysis found predictors of mortality upon recurrence included age older than 50 (hazard ratio 5.19), previous tobacco use (1.40), complicated initial presentation with obstruction (1.33), abscess (2.18), peritonitis (3.14), sepsis (1.88) or fistula (3.50). While mortality was 0.3% for delayed elective surgery after a patient's first episode of diverticulitis, it was 4.6% for emergent resection during a patient's second episode.

The findings offer new information on how best to manage patients with diverticulitis, although they don't resolve the problem, Dr. Rose said. "We can't say definitively that after two episodes everyone should have an operation, because in the end it's a balance of risks and benefits. There's a risk of operating and there's a risk of not operating."

Nevertheless, he and his colleagues conclude, "in view of significantly worse outcomes associated with diverticulitis recurrence, resection should be strongly considered for diverticulitis patients older than 50 years or those who present with a complicated clinical picture."

Dr. Chang, Dr. Rose and their colleagues are currently conducting a similar study on patients with small bowel obstructions.

The authors report no external funding or disclosures.

SOURCE: http://bit.ly/1BqORNI

Ann Surg 2015.