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Continuous evolution of the management of sigmoid diverticulitis

Diverticulitis represents a significant health burden worldwide. The optimal management of uncomplicated diverticulitis and the role of primary anastomosis in perforated diverticulitis remain contentious. Henri Hartmann described his operation for cancer in 1921, and in 1950, Boyden first suggested Hartmann’s procedure as an alternative to the traditional three-stage approach for perforated diverticulitis. The restoration of intestinal continuity following Hartmann’s procedure continues to be associated with significant morbidity, and in addition, up to 50% of patients never undergo reversal. This has prompted surgeons to challenge the traditional dogma of avoiding primary anastomosis in the presence of sepsis. The inherent difficulty of conducting prospective research on surgery for life-threatening emergency conditions has prevented objective comparisons between surgical approaches. In addition, there are infrequent occurrences of critical endpoints such as surgeryspecific mortality, anastomotic leak, intra-abdominal abscess and return to theatre. Meta-analyses comparing primary anastomosis with Hartmann’s procedure have had varying outcomes; Shaban et al. analysed 765 patients in 14 studies, demonstrating a lower mortality following primary anastomosis and a significantly higher rate of permanent stomas following Hartmann’s procedure. An analysis of three randomized controlled trials found no difference in mortality and morbidity, with a lower rate of post-operative abscesses and permanent stomas in the primary anastomosis group, although the authors concluded that all three trials were likely to be underpowered. In the current issue of the journal, Ahmadi et al. examine the outcomes of 103 patients who underwent surgery for acute diverticulitis at a quaternary referral centre over a 13-year period. The authors attribute the increasing rate of primary anastomosis over time to the sub-specialization of surgery and demonstrate comparable morbidity and mortality between primary anastomosis and Hartmann’s procedure. Their findings echo the conclusions of a previous study from West Australia, as well as a study using the American College of Surgeons’ National Surgical Quality Improvement Program surgical risk calculator in 10 780 patients where subspecialization in colorectal surgery was associated with a lower mortality and higher overall rate of performing primary anastomosis. At the other end of the disease spectrum, the traditional management of uncomplicated diverticulitis has involved routine admission for intravenous antibiotics and the graduated resumption of oral intake following a period of bowel rest. Despite several scientific societies recommending outpatient management of selected patients with uncomplicated diverticulitis, hospitalization remains standard practice for more than 75% of colorectal surgeons in Australia and New Zealand. In 1929, the same year when Fleming published his in vitro experiments in the British Journal of Experimental Pathology, Mayo described the condition of ‘self-limiting diverticulitis and peridiverticulitis’ with “...pain in the region of the mass, which is usually palpable, a moderate degree of fever, and gaseous distension. As a rule these symptoms are not severe, and although the temperature may be elevated one or two degrees, the patients are often ambulatory after the first day or two, and the tumour disappears in the course of a few weeks”; this outcome is observed in the pre-antibiotic era. In a review of 10 studies comparing inpatient and outpatient management, similar failure rates (6.5% versus 4.6%) and recurrence rates (13.0% versus 12.1%) were found, and in a metaanalysis of 2303 patients, there was only a 7% readmission rate, 0.4% need for emergency intervention and a 40–80% reduction in overall cost with outpatient treatment. Whilst the data are largely comprised of retrospective reviews and randomized trials with notable limitations, the safety of outpatient management of uncomplicated diverticulitis in well-selected patient groups remains quite convincing. There is a paucity of Australian data documenting experience with the outpatient management of uncomplicated diverticulitis. In this issue of the journal, Juszczyk et al. report the results of implementation of a protocol for outpatient management at a major teaching hospital. The authors report a significant reduction in hospital admission rate (93% versus 39%, P < 0.0001), total hospital admission days (602 versus 370, P < 0.0001) and a total cost saving of AUD $266 288, without any change in emergency re-presentation. Given the escalating financial burden of health care, the potential impact of such savings cannot be ignored. Surgeons and health administrators are encouraged to consider these findings. Diverticulitis remains a complex, evolving topic. Management of perforated diverticulitis must be tailored to the needs of the patient and capabilities of the institution based on high-quality research that informs our clinical decision-making. There are also opportunities for significant cost savings, without compromising care.