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To cut is to cure? Elective resection after percutaneous drainage for diverticular abscess.

Diseases of the Colon & ReCtum Volume 57: 12 (2014) there is perhaps no other disease process that is as commonly encountered yet just as often misunderstood than diverticulitis. Disagreements range from its origin to relationship with dietary intake; the optimal medical therapy versus criteria for observation alone; and the role of surgery, where recommendations remain somewhat of a moving target. uncomplicated disease appears to have an increasing degree of consensus favoring more stringent criteria for operative intervention, even for repeated attacks and young patients. Complicated disease, classically defined as diverticulitis with associated strictures, fistulas, or abscesses, at first glance would also seem to have generalized agreement, with surgery playing a much more prominent role. Yet, when requiring surgeons to provide specific guidance regarding therapy in this cohort, the matter seems to be much more variable. furthermore, there is significant debate regarding questions such as whether diverticulitis is always associated with a perforation, what degree or size of fluid collection constitutes an abscess or complicated disease, and how we should treat the patient who is in remission after successful medical management. the latter of these questions is where the present study attempts to fill in this knowledge gap. in this issue of Diseases of the Colon & Rectum, lamb and colleagues examine the subset of patients with complicated diverticulitis and an abscess, analyzing 22 studies with a total of 1051 patients in this systematic review. specifically, the authors evaluated the outcomes of elective resection versus observation following a diverse array of treatment pathways after the initial successful nonoperative management of the diverticular abscess. focusing on patients with modified hinchey iB and ii, they found that percutaneous drainage was successful in roughly half of all patients, with an equal distribution of patients eventually falling into 1 of 3 categories: 1) urgent surgery at index hospitalization, 2) those going on to elective surgery, and 3) patients requiring no surgery at all. overall, persistent symptoms or disease recurrence remains an important issue, with only 28% of the total population remaining asymptomatic and not undergoing some type of surgical intervention. however, the lack of prospective controlled data and variable management strategies included in this analysis makes it difficult to determine whether that high rate of surgical intervention is more reflective of the actual disease process and natural history or the bias of the managing surgeon and persistent surgical dogma. the authors should be commended for taking on such a difficult task. after all, the significant differences among our expert’s opinions on the disease itself make it even harder to sort through the heterogeneity in the primary studies, not to mention accounting for the wide variety of surgical decision making, anecdotal experience, and practice patterns that go into the care of these patients. Despite these challenges, several patterns in the literature emerge from the authors’ exhaustive review. first, symptomatic recurrence may be more easily defined and categorized in a retrospective study than in an actual clinical scenario. the ability to identify those patients who require urgent surgery, or in the worst case a diverting ostomy, remains an important metric that has a major impact on patient quality of life but is more difficult to objectively quantify and report in a meta-analysis or systematic review. Previous authors have found that a pelvic abscess (versus mesocolic), those of larger size, and concomitant immunosuppression or renal failure are each associated with an increased risk for failure of nonoperative therapy. however, they do not necessarily translate directly to a permanent stoma or surgery; rather, in many cases, they simply predict recurrent symptoms or the need to advance to higher levels of intervention (ie, percutaneous drainage from antibiotics, repeat drain, etc). further muddying the waters, the authors of the present study included patients with hinchey iB and ii abscesses, for whom use of antibiotics and percutaneous drainage have had mixed results. this raises the important question of whether the pooled To Cut Is to Cure? Elective Resection After Percutaneous Drainage for Diverticular Abscess