Young patients with diverticular disease: A preliminary quality of life study

Quality of Life and Persistent Symptoms After Uncomplicated Acute Diverticulitis

BACKGROUND

Although acute diverticulitis and its recurrence are well studied, little is known about the period after these attacks have passed. Many patients appear to be affected by persistent symptoms that impair quality of life. The few published studies on this topic are mostly limited by the lack of CT confirmation of the acute diverticulitis diagnosis, low numbers of patients, or cross-sectional design.

OBJECTIVE

This study longitudinally evaluated quality of life and symptoms after antibiotic or observational treatment of uncomplicated acute diverticulitis.

DESIGN

This was an observational study of randomized clinical trial data.

SETTINGS

This study was conducted at a single tertiary care center.

PATIENTS

Patients with CT-proven, primary, left-sided, uncomplicated acute diverticulitis were randomly assigned to observational or antibiotic treatment.

MAIN OUTCOME MEASURES

Quality of life was assessed using questionnaires (EuroQol 5D, Short Form-36, and Gastrointestinal Quality of Life Index) at baseline and 3, 6, 12, and 24 months after random assignment. Patients were considered to have persistent symptoms when specific quality-of-life scores at the 12- and 24-month follow-ups were among the lowest 16% of scores measured in a healthy reference group.

RESULTS

A total of 528 patients were included. No difference was detected between the observational and antibiotic groups in any quality-of-life score during follow-up. Overall, 32.2% to 38.2% of patients had persistent symptoms after 1 or 2 years, depending on which questionnaire (sub)score was assessed. Risk factors for persistent symptoms based on to the Gastrointestinal Quality of Life index GI symptoms score included a mean pain score ≥3.75 (OR = 2.77 (95% CI, 1.60-4.80)) during the first 10 days of disease and prolonged (≥28 d) time to recovery (OR = 2.25 (95% CI, 1.31-3.88)). Flatulence, rumblings, bloating, fullness, and many stools were the top 5 complaints at the 12- and 24-month follow-ups.

LIMITATIONS

The study was limited by possible selection bias of patients included in a randomized controlled trial.

CONCLUSIONS

More than one third of patients experience persistent symptoms after an episode of acute uncomplicated diverticulitis. Long-term quality of life is comparable after initial antibiotic or observational treatment. See Video Abstract at http://links.lww.com/DCR/A916.

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.

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.

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.

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

PURPOSE

Laparoscopic-assisted sigmoidectomy is a widely applied technique in the operative treatment of diverticular disease. Treatment guidelines recommend operation of complicated diverticulitis and after recurrent attacks of uncomplicated diverticulitis. These guidelines have become subject to controversy. The objective of this study was to assess disease-related quality of life after laparoscopic sigmoidectomy.

METHODS

Data were collected retrospectively. Patients filled in a form describing their quality of life. All patients undergoing elective operation for diverticular disease between 1999 and 2006 at the Department of Surgery of the Uster Hospital, a regional medical center in Switzerland were included. The measurement tool we used is the Gastrointestinal Quality of Life Index (GIQLI). Wilcoxon-Mann-Whitney test or unpaired t-tests were applied to determine statistical significance of differences observed.

RESULTS

A total of 130 patients were included and 120 questionnaires were available for analysis. Mean follow-up was 40 months. Of the total, 48% reported a GIQLI >100 before the operation, which rose to 83% after the operation (p < 0.0001). Mean GIQLI was 95 before and 114 after the operation (p < 0.0001). Female patients reported lower GIQLI rates. Overall, 96% were satisfied with the operation.

CONCLUSIONS

The results in this study population show that in a majority of patients who underwent elective laparoscopic-assisted sigmoidectomy for recurrent diverticulitis gastrointestinal quality of life improved with the operation.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age <or= 50 years). Much of the older literature suggests that young patients experience a more virulent course with diverticulitis. Previous studies have shown misclassification and selection bias. As a result leading to a bias for more severe cases to be recognized mild cases may not be included. Young patients appear more likely to undergo operations to resolve an uncertain diagnosis. Recent studies have raised doubts about a virulent course with diverticulitis suggesting that recurrence may be associated with disease severity on CT scan, and supporting a conservative approach to diverticular disease. The diagnosis of diverticulitis is often delayed in younger patients because it is not considered, resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated. There is a lack of evidence to support the hypothesis that elective surgery should follow a single attack of diverticulitis. Any increased risk appears be a chronologic rather than pathologic phenomenon. Most patients will not have further episodes of diverticulitis.

Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy

OBJECTIVE

To prospectively determine the functional impact of elective laparoscopic sigmoidectomy after prior acute diverticulitis.

SUMMARY BACKGROUND DATA

Decision-analysis for elective colonic resection after acute diverticulitis is predicated on future risk estimates of disease recurrence and complication rates. Quality of life alone is rarely countenanced as sufficient to warrant the supposed risk of intervention.

METHODS

Consecutive patients undergoing laparoscopic sigmoid colectomy for prior diverticulitis over 18 months were studied at baseline (preoperative) and again subsequently (3, 6, and 12 months postoperatively) regarding quality of life and bowel symptomatology [gastrointestinal quality of life index (GIQLI)]. All patients also had enquiry made into urinary and sexual function at the same time points (men underwent international prostate symptom severity and international index of erectile function, respectively, whereas for women the urinary dysfunction index and a modified questionnaire for the evaluation of sexual function were used).

RESULTS

Forty-six patients (mean age 58.3, 26 men) were studied, 45 of whom had their surgery completed laparoscopically. Quality of life significantly improved in the group overall, with 36 patients having an increase in their GIQLI >10 points (23 patients >20 points). This improvement was evident by 3 months and maintained thereafter. The improvement was due to increments in gastrointestinal symptomatology subdomain and was most significant in those with lowest preoperative scoring. Five patients' GIQLI score deteriorated without obvious predictive event. Not one of the patients presented evident alteration in urinary and sexual functioning postoperatively.

CONCLUSIONS

Significant improvement in quality of life and social functioning accrues from elective sigmoid resection in the majority of patients. Avoidance of subsequent episodic attacks therefore should not represent the sole reason for operating but instead patient-centered issues should be prioritized.