Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Quality of life in benign colorectal disease-a review of the assessment with the Gastrointestinal Quality of Life Index (GIQLI)

BACKGROUND AND PURPOSE

The Gastrointestinal Quality of Life Index (GIQLI) is an instrument for the assessment of quality of life (QOL) in diseases of the upper and lower GI tract, which is validated in several languages around the world. The purpose of this literature review is the assessment of the GIQLI in patients with benign colorectal diseases. Reports on GIQLI data are collected from several institutions, countries, and different cultures which allows for comparisons, which are lacking in literature.

METHODS

The GIQL Index uses 36 items around 5 dimensions (gastrointestinal symptoms (19 items), emotional dimension (5 items), physical dimension (7 items), social dimension (4 items), and therapeutic influences (1 item). The literature search was performed on the GIQLI and colorectal disease, using reports in PubMed. Data are presented descriptively as GIQL Index points as well as a reduction from 100% maximum possible index points (max 144 index points = highest quality of life).

RESULTS

The GIQLI was found in 122 reports concerning benign colorectal diseases, of which 27 were finally selected for detailed analysis. From these 27 studies, information on 5664 patients (4046 female versus 1178 male) was recorded and summarized. The median age was 52 years (range 29-74.7). The median GIQLI of all studies concerning benign colorectal disease was 88 index points (range 56.2-113). Benign colorectal disease causes a severe reduction in QOL for patients down to 61% of the maximum.

CONCLUSIONS

Benign colorectal diseases cause substantial reductions in the patient's QOL, well documented by GIQLI, which allows a comparison QOL with other published cohorts.

Platelet to lymphocyte ratio is a risk factor for failure of non-operative treatment of colonic diverticulitis

Non-operative treatment is the mainstay of colonic diverticulitis, but some patients require surgery due to non-operative treatment failure. This study aims to identify risk factors for the failure of non-operative treatment of colonic diverticulitis. From January 2011 to December 2020, we retrospectively reviewed 2362 patients with non-operative treatment for first-attack acute diverticulitis. Patients were categorized into non-operative treatment success or failure groups. Clinical characteristics and serum inflammatory markers were analyzed by multivariable logistic regression to determine risk factors for non-operative treatment failure of colonic diverticulitis. Overall, 2.2% (n = 50) of patients underwent delayed surgery within 30 days (median 4.0 [3.0; 8.0]) due to non-operative treatment failure. Multivariable logistic regression identified that platelet to lymphocyte ratio (odds ratio [OR], 4.2; 95% confidence interval [CI], 0.05-0.13; p < 0.001), diabetes mellitus (OR, 2.2; 95% CI, 0.01-0.09; p = 0.025), left-sided colonic diverticulitis (OR, 4.1; 95% CI, 0.04-0.13; p < 0.001), and modified Hinchey classification (OR, 6.2; 95% CI, 0.09-0.17; p < 0.001) were risk factors for non-operative treatment failure. Platelet to lymphocyte ratio (PLR) is a potential risk factor for the non-operative treatment failure of acute first-attack colonic diverticulitis. Therefore, patients with higher PLR during non-operative treatment should be monitored with special caution.

Long-term bowel dysfunction and decision regret in diverticulitis: A mixed methods study

BACKGROUND

This study had aimed to describe long-term decision regret, bowel dysfunction, and the overall quality of life in patients with diverticulitis, and to determine if elective colectomy was associated with these patient-reported outcome measures.

METHODS

This mixed-methods, survey-based study was administered to a national cohort of patients in the United States with diverticulitis. We measured decision regret (Brehaut Decision Regret), bowel dysfunction (Low Anterior Resection Syndrome score), and the overall quality of life (EuroQol 5 Dimension) in this population. We asked open-ended questions to elucidate factors that influenced patients' choices between elective colectomy and observation.

RESULTS

Among the 614 respondents, 294 (48%) chose between colectomy and observational management, 94 (15%) had surgery, and 157 (26%) had major Low Anterior Resection Syndrome. Of the 294 that chose between colectomy and observational management, 51 (17%) experienced decision regret. Colectomy was associated with an average decrease in the Brehaut Decision Regret score by 6 points but was not associated with a categorical measure of decision regret (Brehaut Score ≥50). Bowel dysfunction and overall quality of life were not significantly associated with colectomy. Disease-related factors, psychosocial factors, and interactions with physicians were commonly cited as reasons for pursuing colectomy or observational management.

CONCLUSION

Patients with self-reported diverticulitis describe high levels of decision regret and bowel dysfunction regardless of chosen management strategy. Physicians should be aware that psychosocial factors can strongly influence a patient's choice between colectomy and observational management. We advocated for future prospective studies using patient reported outcome metrics to improve outcomes in diverticulitis.

Health-related quality of life and functional disorders after diverticular surgery

Diverticulosis and diverticulitis are leading indications for colorectal surgery in Western countries. Abdominal pain, functional disorders, and low health-related quality of life (HRQoL) can limit the outcome of abdominal surgery even in the absence of complications. Therefore, we aimed to review current evidence on postoperative long-term outcomes including HRQoL, functional disorders, abdominal pain, and patients' satisfaction after diverticular surgery for diverticulosis/diverticulitis. We performed a PubMed database search (inception: 17 December 2020). Identified publications were screened and outcome parameters extracted. In summary, HRQoL increased after diverticular surgery in 9 out of 10 longitudinal cohort studies. Similarly, patients' satisfaction with treatment and their choice to undergo surgery was commonly reported as high or very good, as reported in eight studies. In a randomized control trial and retrospective cohort, elective diverticular surgery was superior to conservative treatment regarding HRQoL. In cross-sectional analyses, chronic abdominal pain and functional disorders including defaecation disorders or diarrhoea/obstipation were found in a relevant fraction of patients. Incontinence ranged from 5% to 25% with insufficient data for comparison before and after surgery. However, functional disorders did not result in decreased HRQoL in most studies, and no increase in functional disorders was observed after elective diverticular surgery in longitudinal analyses. We conclude that HRQoL among operated patients with diverticular disease improved in most studies after surgery. Functional disorders and postoperative abdominal pain can be present after elective diverticular surgery; however, no increase in functional disorders was observed in longitudinal studies. Functional disorders after diverticular surgery need to be carefully discussed with the patient before surgery and a careful clinical assessment before surgery including incontinence scoring should be considered.

What Are the Long-Term Changes to Bowel Function Patient-reported Outcomes After Elective Sigmoidectomy for Diverticular Disease?: Observational Study of Patients Undergoing Elective Sigmoidectomy for Diverticular Disease

Objective

To evaluate long-term changes to bowel function after elective sigmoidectomy for diverticular disease.

Background

For patients with diverticular disease, choosing surgery is often based on the presumption of improvement in preoperative symptoms. Our group previously reported bowel function does not change in the early perioperative period; however, studies of long-term outcomes are limited.

Methods

This is an observational study of patients that underwent elective sigmoidectomy for diverticular disease and completed the Colorectal Functional Outcome (COREFO) questionnaire before surgery. Patients were stratified into two groups based on presence or absence of a preoperative symptomatic score (i.e., total COREFO ≥ 15). Long-term bowel function (>1 year from surgery) was assessed using the COREFO questionnaire via telephone or subsequent clinic visit. Paired t-tests compared mean preoperative scores to mean long-term scores.

Results

Fifty-one patients met inclusion criteria (21 symptomatic, 30 asymptomatic). All symptomatic patients had uncomplicated disease, whereas 90% of asymptomatic patients had complicated disease. Median time from operation to questionnaire completion was 23 months (IQR = 13-34). Asymptomatic patients demonstrated impaired bowel function, predominantly driven by changes in the social impact domain. Symptomatic patients demonstrated improved bowel function, driven by changes in the incontinence, social impact, stool-related aspects, and need for medication domains.

Conclusions

In the long-term after elective sigmoidectomy for diverticular disease, patients with symptomatic bowel function preoperatively improve substantially, while those with asymptomatic preoperative scores demonstrate statistically significant impairment. Patients determined to be symptomatic with patient-reported outcomes likely benefit long-term from sigmoid resection.Mini-Abstract: In this manuscript, long-term changes to patient-reported bowel function were assessed using a validated questionnaire after sigmoidectomy for diverticular disease. We found that in patients with symptomatic preoperative bowel function, long-term bowel function improved after elective resection. Alternatively, patients with asymptomatic preoperative bowel function demonstrated long-term impairment in bowel function.

Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized Clinical Trial

Question

Does elective sigmoid resection improve the quality of life in patients with recurrent diverticulitis, complicated diverticulitis, and/or chronic pain after an episode of diverticulitis?

Findings

In this randomized clinical trial that included 85 adults, the Gastrointestinal Quality of Life Index (GIQLI) score improved 11.8 points in patients randomized to sigmoid resection and 0.2 points in patients randomized to conservative treatment between baseline and 6 months, a statistically and clinically significant difference. Among 41 patients randomized to sigmoid resection, 4 (10%) experienced major complications.

Meaning

Sigmoid resection improved quality of life in patients with recurrent, complicated, or persistent painful diverticulitis but was associated with a small but significant risk of major complications.

Importance

Diverticulitis has a tendency to recur and affect quality of life.

Objective

To assess whether sigmoid resection is superior to conservative treatment in improving quality of life of patients with recurrent, complicated, or persistent painful diverticulitis.

Design, Setting, and Participants

This open-label randomized clinical trial assessed for eligibility 128 patients with recurrent, complicated, or persistent painful diverticulitis in 6 Finnish hospitals from September 29, 2014, to October 10, 2018. Exclusion criteria included age younger than 18 years or older than 75 years; lack of (virtual) colonoscopy or sigmoidoscopy data within 2 years, or presence of cancer, contraindication to laparoscopy, or fistula. Outcomes were assessed using intention-to-treat analysis. A prespecified interim analysis was undertaken when 66 patients had been randomized and their 6-month follow-up was assessable. Data were analyzed from June 2018 to May 2020.

Interventions

Laparoscopic sigmoid resection or conservative treatment.

Main Outcomes and Measures

The primary outcome was difference in Gastrointestinal Quality of Life Index (GIQLI) score between randomization and 6 months.

Results

Of 128 patients assessed for eligibility, 90 were randomized (28 male [31%]; mean [SD] age, 54.11 [11.9] years; 62 female [69%]; mean [SD] age, 57.13 [7.6] years). A total of 72 patients were included in analyses for the primary outcome (37 in the surgery group and 35 in the conservative treatment group), and 85 were included in analyses for clinical outcomes (41 in the surgery group and 44 in the conservative treatment group). The difference between GIQLI score at randomization and 6 months was a mean of 11.96 points higher in the surgery group than in the conservative treatment group (mean [SD] of 11.76 [15.89] points vs −0.2 [19.07] points; difference, 11.96; 95% CI, 3.72-20.19; P = .005). Four patients (10%) in the surgery group and no patients in the conservative treatment group experienced major complications (Clavien-Dindo grade III or higher). There were 2 patients (5%) in the surgery group and 12 patients (31%) in the conservative treatment group who had new episodes of diverticulitis within 6 months.

Conclusions and Relevance

In this randomized clinical trial, elective laparoscopic sigmoid resection improved quality of life in patients with recurrent, complicated, or persistent painful diverticulitis but carried a 10% risk of major complications.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174926.

Quality of life in uncomplicated recurrent diverticulitis: surgical vs. conservative treatment

Elective sigmoid colectomy for recurrent uncomplicated diverticulitis remains controversial and is decided on an individual basis. Eighty patients treated conservatively (44 patients) or by elective surgery (36 patients) for recurrent uncomplicated diverticulitis were contacted and assessed for quality of life. The mean difference in quality of life scores was greater after surgery (overall + 2.14%, laparoscopic resection +4.95%, p = 0.36 and p = 0.11, respectively) as compared to conservative management. Female patients undergoing laparoscopic resection had statistically significantly higher quality of life scores than women treated conservatively (+8.98%; p = 0.049). Twenty-eight of 29 responding patients stated that they were highly satisfied and would have the operation done again. Elective sigmoidectomy is a valid treatment option for recurrent uncomplicated diverticulitis in terms of quality of life. Quality of life improved most if surgery was performed laparoscopically, especially in women.

Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial)

OBJECTIVE

The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints.

SUMMARY OF BACKGROUND DATA

The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up.

METHODS

From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome.

RESULTS

At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients.

CONCLUSION

Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.

Cost-effectiveness analysis of a multicentre randomized clinical trial comparing surgery with conservative management for recurrent and ongoing diverticulitis (DIRECT trial)

Background

The results of the DIRECT trial, an RCT comparing conservative management with elective sigmoid resection in patients with recurrent diverticulitis or persistent complaints, showed that elective sigmoid resection leads to higher quality of life. The aim of this study is to determine the cost-effectiveness of surgical treatment at 1- and 5-year follow-up from a societal perspective.

Methods

Clinical effectiveness and resource use were derived from the DIRECT trial. The actual resource use and quality of life (EQ-5D-3L™ score) were documented prospectively per individual patient and analysed according to the intention-to-treat principle for up to 5 years after randomization. The main outcome was the incremental cost-effectiveness ratio (ICER), expressed as costs per quality-adjusted life-year (QALY).

Results

The study included 106 patients, of whom 50 were randomized to surgery and 56 to conservative treatment. At 1- and 5-year follow-up an incremental effect (QALY difference between groups) of 0·06 and 0·43 respectively was found, and an incremental cost (cost difference between groups) of €6957 and €2674 respectively, where surgery was more expensive than conservative treatment. This resulted in an ICER of €123 365 per additional QALY at 1-year follow-up, and €6275 at 5 years. At a threshold of €20 000 per QALY, operative treatment has 0 per cent probability of being cost-effective at 1-year follow-up, but a 95 per cent probability at 5 years.

Conclusion

At 5-year follow-up, elective sigmoid resection in patients with recurring diverticulitis or persistent complaints was found to be cost-effective. Registration number: NTR1478 (www.trialregistrer.nl).

Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease

The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.

Recurrences and Ongoing Complaints of Diverticulitis; Results of a Survey among Gastroenterologists and Surgeons

OBJECTIVE

This study aims to investigate the current opinion of gastroenterologists and surgeons on treatment strategies for patients, with recurrences or ongoing complaints of diverticulitis.

BACKGROUND

Treatment of recurrences and ongoing complaints remains a point of debate. No randomized trials have been published yet and guidelines are not uniform in their advice.

DESIGN

A web-based survey was conducted among gastroenterologists and GE-surgeons. Questions were aimed at the treatment options for recurrent diverticulitis and ongoing complaints.

RESULTS

In total, 123 surveys were filled out. The number of patients with recurrent or ongoing diverticulitis who were seen at the outpatient clinic each year was 7 (0-30) and 5 (0-115) respectively. Surgeons see significantly more patients on an annual basis 20 vs. 15% (p = 0.00). Both surgeons and gastroenterologists preferred to treat patients in a conservative manner using pain medication and lifestyle advise (64.4 vs. 54.0, p = 0.27); however, gastroenterologists would treat patients with mesalazine medication, which is significantly more (28%, p = 0.04) than in the surgical group. Surgeons are inclined more towards surgery (31.5%, p = 0.02).

CONCLUSIONS

Both surgeons and gastroenterologists prefer to treat recurrent diverticulitis and ongoing complaints in a conservative manner. Quality of life, the risk of complications and the viewpoint of the patient are considered important factors in the decision to resect the affected colon.

Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.

METHODS

We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854).

RESULTS

We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment.

CONCLUSIONS

On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality.

A Markov Decision Model to Guide Treatment of Recurrent Colonic Diverticulitis

BACKGROUND & AIMS

Although colonic diverticulitis is a common disorder, there is no clear treatment strategy for patients with recurrent episodes of diverticulitis. We investigated whether colonic resection or conservative or medical treatments have the greatest effects on quality-adjusted life-years (QALYs).

METHODS

A Markov model simulating patients with 2 episodes of non-surgically treated diverticulitis was used to simulate all relevant outcomes of each treatment strategy. A 1-year cycle length with 10-year follow-up period was used to allow for chance of recurrent diverticulitis. Primary outcome was QALYs gained from each strategy. Factors considered were morbidity, mortality, chance of colostomy formation, risk of recurrence, and persistence of abdominal pain. The probabilities of clinical events were determined by using the best available published data.

RESULTS

A strategy in which colonic resection was performed after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival (a gain of 8.66 QALYs) and highest chance of stoma formation (1.1%) but the lowest chance of a mild (3.5%) or severe (1.1%) recurrence. The strategies of colonic resection or conservative or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, providing 8.78, 8.76, and 8.74 QALYs, respectively. Probabilistic sensitivity analysis did not change these results. Persistent abdominal complaints were lowest in the medical treatment strategy.

CONCLUSIONS

Elective surgery after 2 episodes of diverticulitis should be questioned in terms of QALYs. After the third episode of diverticulitis, surgical or conservative or medical treatments provide similar QALYs, but rates of abdominal symptoms are lower with the medical treatment strategy. This Markov decision model has limitations when the individual patient and physician face a complex decision weighing early and long-term risks and benefits of elective surgery or conservative management.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

Constipation is not associated with diverticular disease - Analysis of 976 patients

BACKGROUND

In the light of controversial data in the literature, the present study was designed to evaluate potential associations between colonic diverticular disease, constipation and quality of life.

DESIGN

We prospectively enrolled 976 consecutive patients, who participated in the nationwide colorectal cancer screening program in four medical centers between 2008 and 2009. All patients underwent full colonoscopy and completed a standardized questionnaire. The severity of constipation was assessed by the validated Wexner constipation score. Quality of Life (QOL) was evaluated by the SF-12 health score.

RESULTS

The median age was 62 years (range 22-90) and the male to female ratio was 1:1. Colonic diverticular disease was found in 290 participants (30%). Age, body mass index and diabetes mellitus were significantly associated with the presence of diverticular disease (p < 0.0001, p = 0.0007 and p = 0.0178). The median constipation score in patients with diverticular disease was 3 (range 0-18), and comparable to patients without diverticula (p = 0.1073). The physical component summary of the SF-12 was significantly reduced in patients with diverticular disease (p = 0.0038).

CONCLUSION

This large population based study revealed no association between colonic diverticular disease and constipation. Notably, the presence of diverticular disease significantly impacts quality of life.

Sigmoid stricture associated with diverticular disease should be an indication for elective surgery with lymph node clearance

BACKGROUND

The literature concerning stricture secondary to diverticulitis is poor. Stricture in this setting should be an indication for surgery because (a) of the potential risk of cancer and (b) morbidity is not increased compared to other indications for colectomy. The goal of this report is to study the post-surgical morbidity and the quality of life in patients after sigmoidectomy for sigmoid stricture associated with diverticular disease.

METHOD

This is a monocenter retrospective observational study including patients with a preoperative diagnosis of sigmoid stricture associated with diverticular disease undergoing operation between Jan 1, 2007 and Dec 31, 2013. The GastroIntestinal Quality of Life Index was used to assess patient satisfaction.

RESULTS

Sixteen patients were included of which nine were female. Median age was 69.5 (46-84) and the median body mass index was 23.55kg/m(2) (17.2-28.4). Elective sigmoidectomy was performed in all 16 patients. Overall, complications occurred in five patients (31.2%) (4 minor complications and 1 major complication according to the Dindo and Clavien Classification); none resulted in death. Pathology identified two adenocarcinomas (12.5%). The mean GastroIntestinal Quality of Life Index was 122 (67-144) and 10/11 patients were satisfied with their surgical intervention.

CONCLUSION

Sigmoid stricture prevents endoscopic exploration of the entire colon and thus it may prove difficult to rule out a malignancy. Surgery does not impair the quality of life since morbidity is similar to other indications for sigmoidectomy. For these reasons, we recommend that stricture associated with diverticular disease should be an indication for sigmoidectomy including lymph node clearance.

The relation between quality of life and histopathology in diverticulitis; can we predict specimen-related outcome?

PURPOSE

An important factor in the decision to perform laparoscopic sigmoid resection for patient suffering from recurrent and ongoing diverticulitis is quality of life (QoL). It is unknown whether quality of life relates to the severity of diverticulitis as seen in the resected colonic segment. The aim of this study is to analyze histopathological findings of patients suffering from recurrent or ongoing diverticulitis and their QoL before and after surgery in order to improve patient outcome prediction.

METHODS

A cohort of consecutive patients with diverticulitis between January 2010 and April 2014 was analyzed. All patients were scheduled for surgery and had at least three episodes of diverticulitis or more within the last 2 years or experienced ongoing complaints for at least 3 months or more and confirmation by a radiologist. We compared QoL questionnaires, to known histopathological entities.

RESULTS

For this study, 54 consecutive patients were included, 15 (27.8%) men and 39 (72.2%) women. A marked difference in quality of life before and after surgery for patients having a more severe histopathological entity was not found (p = 0.83). However, a clinically relevant higher VAS score 6 months after surgery was shown in patients with peritonitis. Furthermore, these patients had more fibrosis in the histopathological samples.

CONCLUSION

In conclusion, even though a relation between the different pathological entities and QoL could not be determined, patients with diverticulitis and concomitant microscopic peritonitis had significantly more fibrosis and suffered from a higher VAS scores 6 months after surgery.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Does the presence of abscesses in diverticular disease prelude surgery?

BACKGROUND

Information on long-term outcome of patients treated conservatively for diverticular abscess is scarce. This study aims to compare diverticulitis patients with abscess to patients without abscess with regard to readmission, complications, and surgical treatment during a follow-up period of at least 12 months.

METHODS

A chart review of all patients admitted for a primary manifestation of diverticulitis between January 2005 and January 2011 was performed.

RESULTS

Fifty-nine patients with abscess and 663 without abscess were identified. Median follow-up was 28 months (range 12-103). Initial conservative management was achieved in 54 (91.5 %) patients with diverticular abscess and 635 (96.8 %) without abscess. Readmission occurred more frequently among patients with abscess (hazard ratio (HR) 2.6; confidence interval (CI) 1.51-4.33) with a first-year risk of 27.3 versus 10.7 % and second-year risk of 8.2 versus 4.6 %. Surgery was more frequently performed in patients with diverticular abscess (HR 2.3; CI 1.42-3.66). The first-year risk was 35.1 versus 16.6 % and second-year risk was 12.9 versus 2.4 %. The most frequent indication for surgery was persisting or recurrent disease.

CONCLUSION

Patients with diverticular abscess have a higher risk of being readmitted and/or requiring surgical treatment. The pattern suggests that readmission and need for surgery are the results of an ongoing inflammation of the initial episode.