ACPGBI Position Statement on Elective Resection for Diverticulitis

Diverticular disease is common, with a frequency that increases with age. Most patients with diverticulosis do not develop symptoms, though a number will develop inflammation or diverticulitis. This inflammation may develop into an abscess or free perforation. Whilst the prevalence of perforation has increased from 2.4 per 100 000 in 1986 to 3.8 per 100 000 in 2000 according to one study [1], the majority of patients with diverticulitis follow an indolent clinical course. There has been controversy, therefore, as to whether elective resection after acute diverticulitis is justified [2]. This position statement is presented in sections dealing with the pathology, symptomatology and investigation of diverticular disease and its consequences. It then examines the evidence and indications for surgical intervention and its timing. The issue of laparoscopic versus open resection is then considered. The evidence is briefly summarized under the heading 'Findings' and this is followed where relevant by 'Recommendations'. Organized searches of the Cochrane Database, MEDLINE and PUBMED were performed using the keywords relevant to each section of this Position Statement. Searches were limited predominantly to English language articles. Additional publications were retrieved from the references cited in articles identified from the primary search of the literature. All evidence was classified according to an accepted hierarchy of evidence and recommendations graded A–C on the basis of level of associated evidence and/or noted as Good Practice and/or part of NICE/SIGN recommendation for Rapid Technology Appraisal (Table 1). In Western countries, the prevalence of diverticular disease has dramatically increased over the last century. There is a close link between diverticulosis and a low-fibre diet. The refining of flour with removal of dietary fibre that became increasingly frequent in the late 19th century has been implicated in the aetiology of this disease [3]. Diverticular disease is much less common in the developing world where a high-roughage diet is commonplace. In western populations, vegetarians have a lower frequency of diverticulosis, supporting the hypothesis that a high-roughage diet protects against diverticular disease [4]. In addition, animal studies have also shown that a life-long low-fibre diet is associated with diverticulosis [5] and studies of immigrants demonstrate development of the western pattern of disease when a western diet is adopted. Multiple other factors have been implicated in the aetiology of diverticular disease, including obesity [6], lack of exercise [7], smoking [8] and immunosuppression. The high prevalence of diverticulosis is in part due to an increase in detection of the disorder. However, diverticular disease of the colon increases with age and these increases may also reflect our ageing population [9]. In western countries, over half of the population over 80 years of age has diverticula involving the colon. The incidence increases from about 5% in the fifth decade to 60% in the ninth decade. There appears to be a small female predominance [10] although some older papers suggested male predominance and this might represent a changing distribution of disease. Colonic diverticula are formed by a combination of increased intraluminal pressure in the colon and weakness of the muscular wall. In the weak areas of the colonic wall where blood vessels enter, mucosal herniation occurs. A low-fibre diet results in small-volume stools that require high intraluminal pressures for propulsion (≥ 150 mgHg). Colonic manometry studies undertaken in the 1960s confirmed higher luminal pressures in patients with diverticulosis than in controls [11]. Subsequently, Painter et al. suggested a theory of segmentation in which muscle contraction results in a series of discrete segments of bowel with high intraluminal pressures [12]. This disordered motility is likely to have a major role in the pathogenesis of both left-sided and right-sided diverticula. Patients with ulcerative colitis have reduced bowel wall muscle tone and contractility. This may explain the lower prevalence of diverticulosis in patients with ulcerative colitis [13]. Increased cholinergic neural activity and decreased noncholinergic activity has been demonstrated in diverticulosis [14]. This alteration could lead to increased tonicity but it is unclear whether this finding is causally related [4]. Decreased numbers of glial cells and interstitial cells of Cajal have also been recently described in patients with diverticular disease. This finding might explain some of the large bowel motility disturbances [15]. Solitary caecal diverticulum is an uncommon congenital condition; caecal diverticula are seen more commonly as part of generalized diverticular disease and were seen in 16% of patients in the postmortem study reported by Hughes [16]. Right-sided diverticulosis in the absence of left-sided disease is considered to be a different condition with a genetic predisposition. It is seen rarely in Caucasians but more commonly found in Asians and is the predominant site in Japanese patients [17]. Diverticulitis is acute inflammation of one or more diverticula and usually the inflammatory changes involve the apex of the diverticulum rather than the neck. It is likely that acute inflammation is caused by impaction of faecal material within the diverticulum, leading to mucosal ulceration with associated acute inflammation [7]. It has also been suggested that a fibre-deficient diet may be associated with a change in the bacterial flora and alteration of local immunity, resulting in low grade chronic inflammation. This could predispose to acute diverticulitis [18]. Acute inflammation may rapidly involve the serosal surface, leading to peritonitis because of the thinness of the diverticular wall, and there may be localized abscess formation or perforation due to damage of the diverticular wall by acute inflammation. An inflammatory mass may develop with or without involvement of other pelvic organs and fistulation most often to the bladder or vagina occurs particularly in patients who have had previous hysterectomy. Massive rectal bleeding may occur related to erosion of a blood vessel by the inflammatory process, usually at the neck of the diverticulum [19]. In clinical practice, patients present with abdominal pain, most usually in the left iliac fossa. On occasion, pain may be in other areas of the abdomen, either because of a long redundant sigmoid loop lying on the right side of the abdomen or because of diverticular disease located away from the sigmoid colon. The pain may be associated with systemic symptoms such as nausea and vomiting or anorexia. Physical signs will usually include localized tenderness and guarding, fever, and there may be a palpable mass either in the abdomen or per rectum. Where an inflammatory mass is present in the absence of an abscess, this is generally termed a phlegmon. The condition may progress to an abscess or a free perforation. Where an abscess or free perforation develops, the classification proposed by Hinchey [20] can be useful, as shown in Table 2. Other complications of diverticulitis include fistulation, where an abscess ruptures into an adjacent organ or the skin. The common sites are the bladder (colovesical) or the vagina (colovaginal) and are characterized by the passage of flatus or faeces per urethra or vagina. Rarely, other sites such as the uterus, fallopian tube, ureter and small bowel may be involved. Obstruction may occur due to narrowing of the bowel lumen from chronic inflammation. Haemorrhage is a rarer complication, characterized by dark, painless and usually self-limiting bleeding. Angiography may be helpful, with surgery only rarely required for this indication. Diverticulitis without abscess, perforation or fistulation is described as uncomplicated, whilst the presence of any of these features, stenosis or bleeding is termed complicated diverticulitis. Many conditions mimic diverticulitis. The presence of incidental diverticulosis is common. Irritable bowel syndrome often co-exists with diverticulosis and may account for the high rate of recurrent symptoms in some series of patients undergoing resection for diverticular disease (IV). The clinician always needs to consider the differential diagnosis of diverticulitis. Patients should not be told that they have diverticulitis unless there is colonoscopic and/or radiological evidence of inflammation in the presence of diverticular disease (GP). The differential diagnosis for diverticulitis and its sequelae is extensive. Of particular importance are three conditions: colitis, malignancy and irritable bowel syndrome. Diverticular colitis is a distinct but under-recognized entity in patients with sigmoid diverticular disease [21]. It manifests as patchy or confluent inflammation in the sigmoid colon, often sparing the orifices of diverticula. Histological features can closely resemble ulcerative colitis, Crohn's disease, mucosal prolapse or ischaemic colitis [22]. Diverticulitis and diverticular colitis may be associated with histological evidence of granuloma formation. Diverticular colitis may respond to therapy used for chronic inflammatory bowel disease, further confusing the picture [23]. Diverticular strictures may pose a difficult diagnostic conundrum, especially if they are impassable with a colonoscope. CT and barium enema have a significant false negative rate in detecting underlying carcinoma and if there is any doubt, then resection is recommended. In one series of 19 patients with a sigmoid stricture, 15 patients underwent resection, of whom, six had an underlying cancer. In the remainder, the aetiology of the stricture was diverticular disease [24]. The prevalence of irritable bowel syndrome (IBS) is quoted as 5–11% [25] in western populations. One report indicates that in a group of individuals with diverticular disease 14% exhibited characteristics of IBS [26]. Clearly, with symptoms of pain and bowel disorder with both conditions, it is difficult to attribute pain to diverticular change without clear evidence of inflammation. Even after resection of diverticulitis, up to 27% of patients continue with pain. This may be related to co-existing IBS but it has been suggested that IBS types of symptoms may be a sequelae to diverticulitis in some patients. An alternative reported by Horgan et al. [27] is what they label as 'smoldering' diverticular disease with evidence of acute or chronic inflammatory change in the resected specimen. However, while most of their patients benefitted from resection, 24% continued with some symptoms. In advising patients on treatment for diverticular disease, the crossover in symptoms with IBS needs to be borne in mind and form part of the counselling of the patient. Breen et al. reviewed 100 consecutive elective resections for presumed diverticular disease and showed that 24% of resected specimens had no histological evidence of inflammation [28]. Patients without histological evidence of inflammation were significantly more likely to present with abdominal symptoms and suffer persistent postoperative pain, suggesting that the underlying initial pathology was not one of diverticulitis but rather an alternative diagnosis such as IBS. The diagnosis of diverticulitis should be confirmed during the acute attack by radiological means. The modality should be CT or ultrasound depending on local expertise (Level IIb). Barium enema or colonoscopy after resolution of the acute episode is essential to rule out alternative diagnoses or second pathologies. CT or ultrasound should be undertaken during the acute presentation of diverticulitis. This helps to confirm the diagnosis, guide management of the acute attack and occasionally will demonstrate other pathologies. Investigation of the colonic lumen by endoscopic means or barium enema after the acute attack is mandatory (Grade C). Radiographic evaluation of diverticulitis during the acute attack heightens the precision of the decision making process. Evaluation in the first 72 h of an acute attack will help confirm the diagnosis and may give some prognostic information. Confirming the diagnosis is particularly important in the younger patient group, in whom the alternative diagnoses (particularly appendicitis) need to be considered. In patients in whom elective resection is being contemplated, evidence of definite inflammation during the acute attack is essential. Colonoscopic or barium enema evaluation some weeks after the acute attack may show diverticulosis but will not prove the diagnosis of diverticulitis. The optimum radiological modality for evaluation of acute diverticulitis has been the subject of a recent systematic review [29]. This appraised 20 articles evaluating ultrasound, CT, barium enema and MRI. It concluded that the studies were generally of poor quality and suggested that the best study evaluating ultrasound and CT reached only level IIb. Whilst the best evidence in the literature supports ultrasound, the appropriateness of this modality will depend on local expertise. Ultrasound and CT are superior to contrast enema or colonoscopy in that they evaluate the extraluminal extent of the disease and may be more useful in picking up other pathologies. Extraluminal air/contrast and abscess may predict poor outcome (see Table 3). The outcome, however, is mixed and individual predictions are difficult on purely radiological grounds, as 24% with successful conservative management had severe CT diverticulitis and 19% with severe CT diverticulitis, had no further problems, within the context of this study [30]. The diagnostic and therapeutic approach, however, has clearly changed with CT [31–33]. This particularly relates to the confirmation of diagnosis, but also the distinction between uncomplicated, phlegmonous diverticulitis and complicated diverticulitis, involving fistula, peritonitis, obstruction and abscess [34,35]. It is in the treatment of abscesses that a difference of opinion emerges. Ambrosetti and colleagues state that mesocolic abscesses can be managed conservatively without percutaneous drainage [36]. This can be either as a bridge to one-stage resection, or more intriguingly as totally conservative treatment. Longer term follow up of mesocolic and pelvic diverticular abscess, with initial nonsurgical management, shows that 51% of patients with mesocolic and 71% with pelvic abscess eventually require surgery [37]. In this respect, CT acts as a guide to ultimate failure of conservative treatment. Pelvic abscesses, on the other hand, will usually require surgery [35]. The majority of patients presenting with acute diverticulitis can be managed with a conservative, medical approach in the longer term. Previous blanket recommendations for elective resection following acute diverticulitis can be challenged (Level III). The decision on elective resection should be made on an individual basis after the assessment of the particular circumstances of the patient (Grade C). The evaluation of recurrent or persistent symptoms is difficult due to the overlap of symptomatology with conditions such as irritable bowel syndrome, as previously described. Furthermore, it would be reasonable to argue that the medical treatment of acute diverticulitis was transformed in UK practice in the mid 1970s with the introduction of metronidazole [38]. The situation was somewhat different in the US, where the perceived genotoxicity of metronidazole limited its early uptake. The alternatives at that time for treatment of anaerobic infection, lincomycin and clindamycin, were both associated with an associated risk of Clostridium difficile infection. Care should therefore be exercised, when interpreting historical outcomes. The pivotal paper, informing previous recommendations, was that of Parks in 1970 [39]. This was a hospital-based study from 1951 to 1965 with significant exclusions. One can take issue with the diagnostic criteria employed, because barium enema in particular has largely been supplanted by the use of CT. Interestingly, despite the paper's recommendation of elective resection, the evidence at that time could have supported the opposite view, given that only 6% of patients following a first attack of acute diverticulitis required surgery for subsequent recurrent attacks. Farmakis et al. reported on GP questionnaires giving follow-up data from a UK national audit in the 1980s and argued the case for interval sigmoid on recurrent symptoms, complications and there were in the particularly follow at and significantly high of from disease. In the a clear distinction between elective surgery for of symptoms and the risk of recurrent acute particularly severe and and especially on evidence of recurrent on CT or surgical then in including formation and from other an approach a picture of the of diverticulitis and best surgical decision making on elective The are therefore of or an outcome due to a second or subsequent attack of diverticulitis. The need for elective surgery is in part by the primary resection rate at attack and this can from to to UK practice, showed that conservative medical therapy is in with a rate of per The rate for primary surgery will by practice from primary to diagnostic criteria ultrasound contrast enema and indications diverticulitis, fistula, stricture, bleeding and surgical and of CT drainage A high surgical has been used in the to elective surgical intervention but it is to of primary surgery to acute the data presented by et al. can be in a to a conservative approach, as with a blanket recommendation for interval elective of the study group could be to Furthermore, of patients who with perforation have no of diverticulitis and 60% of patients undergoing surgery for acute diverticulitis have no Of patients presenting with acute diverticulitis, only have had a previous episode of acute diverticulitis The is that complicated diverticulitis to occur and that the majority of patients have no previous of disease, though this has not been from a failure to interval elective with symptoms or or and acute diverticulitis, with or without are to late major of radiological criteria can this (Table 3). in a by Ambrosetti on the evaluation of patients after first had a persistent diverticulitis, recurrent diverticulitis, abscess and with no radiological evidence of a diverticulitis underwent surgery for persistent pain or of This group of resections is to late major complications and and not have further after treatment of the attack The most data on the role of elective resection from a limited number of studies with follow up of and Ambrosetti showed that of patients first attack was not suffer a complication, at a follow up of from was common In a study of the prognostic role of CT to elective resection or management had to be because only of patients recurrent diverticulitis, after a limited follow up of 19 and colleagues follow up at and years on a of patients to surgery and complications were of elective has been to which of clinical over time recurrent diverticulitis, from surgical and The risk of recurrent diverticulitis is not by surgery and elective has a of and rate of that management should be associated with lower of and and lower can that there is clinical and evidence against the previous recommendations for elective There is no clear evidence that younger patients presenting with diverticulitis a more form of the disease. The higher of surgery in younger patients in some studies may to or a that they are lower risk for surgical intervention (Level III). the of diverticulitis in younger patients not being there is evidence to a different management in patients to older (Grade C). It has previously been suggested that diverticulitis in the younger patient a more course. This in has been used to a recommendation that such patients should elective following medical management of a first attack of diverticulitis This up to from a number of that the of the the age of the reported younger group has been from under years to under the of it may be more to take age as the The quoted studies involve small numbers and are generally case with often of follow There is a with lack of of of disease. by et al. in the Hinchey Of is more in the younger age group (particularly appendicitis) and this is likely to the surgical It has to high surgery in the The however, is a failure to the issue of to the indications for surgical or medical management and also indications for subsequent elective or the undergoing surgery as for elective a somewhat symptoms and frequency of presentation are other criteria that can be used An in the could be by a high rate of recurrent diverticulitis, high high rate of surgery or high of showed that the rate at was with Furthermore, the rate for both elective and is higher in the years age a low rate for there is for an approach, as this is to lead to use of CT in the diagnosis and management of acute diverticulitis in the younger patient is particularly It a more diagnosis and for between and severe diverticulitis (Table 3). a surgery was performed less in younger patients than older patients and this in of a increased in the Ambrosetti poor outcome as persistent diverticulitis, recurrent diverticulitis, or The were more likely to have a poor outcome longer term follow up there was a rate of The frequency at was in patients with CT severe diverticulitis and this was used to a recommendation for elective in this group However, for the individual is and of surgery only if it or It is that of patients for a first or subsequent attack of diverticulitis, an outcome evidence against elective resection is by and colleagues Of patients years with acute diverticulitis, 60% had surgery and of a of patients with follow up of only one with perforation. In younger patients with acute diverticulitis do not a more course. on the of elective in the younger patient should on individual circumstances of diverticular disease should involve resection to bowel with the rectum. It may not be to diverticular disease. The should be (Level IIb). The should be for diverticular disease This the being made from bowel being to the (Grade The of resection of diverticular disease may The should be made the as the presence of sigmoid colon to the is an of The of resection is more though there is no evidence to resection of The part of the should be made in colon. This is in with the recommendations of the of the of and Practice for Diverticulitis This approach is by of the in patients. In a recent higher of disease after both open and laparoscopic resection, the rate of was low There is some evidence that patients with more limited diverticular resections have a to have recurrent symptoms resection of diverticulitis to patients when performed in with the expertise with open resection (Level In with the laparoscopic resection should be for diverticulitis as it is and a time from surgery (Grade resection for diverticulitis is a alternative to open resection and may be associated with a lower rate of and There have been laparoscopic and open resection of diverticular disease, one reported in form only at this The patients between open and laparoscopic surgery significantly longer and the rate was there was less blood pain and and a significant in from to in the laparoscopic A further from has been reported patients were time was longer in the laparoscopic to first bowel was in the laparoscopic group, pain was less and The rate was have been reported for a study that showed a in from to in of laparoscopic resection though the of in the open group to be A recent of a number of studies also suggested a in and complications This a large number of patients from a study by et al. in which an number of the patients as had an open were in laparoscopic and to the data in of the this study and the may be subject to from the to less being There has recently been a report from a of consecutive patients presenting with complicated and diverticulitis undergoing laparoscopic resection was and major in time was the rate was and was This study showed what can be in with laparoscopic expertise but the of these results is not The laparoscopic approach is for complicated diverticulitis (Level III). In with laparoscopic resection could be for complicated diverticulitis. It may to patient (Grade Patients with complicated or diverticulitis undergoing laparoscopic resection are at higher risk of with with diverticulitis In a recent study between patients with and with complicated diverticular disease, there was a more postoperative in patients with complicated diverticulitis, with a of though over of patients in this group were managed The decision about whether to complicated diverticulitis the to take into account surgical expertise. can be and though results are reported in the these may not be Patients undergoing laparoscopic resection of diverticulitis should be after from the acute episode of inflammation (Level III). the patient with acute diverticulitis should be managed with surgery being after from the acute are lower in the surgery patients and there may be a a lower rate of complications (Grade There are data in the literature to laparoscopic resection in the acute of diverticulitis in to resection, in patients acute can be managed A recent review of whom had early laparoscopic resection with the resection and not between the the rate in the early surgery group was three higher at A study of patients patients early resection with It found less in the surgery group and a lower rate of The role of laparoscopic intervention in the patient presenting with diverticular peritonitis or not conservative management It is whether these patients should interval resection (Level IIb). with and without may a role in some patients with acute diverticulitis. Whilst this is an alternative to resection in the acute for some it is not whether it is an acute alternative to resection (Grade C). can be for diagnosis of acute diverticulitis but in is rarely in the of There have been a number of of laparoscopic for patients with acute diverticulitis. The series in the by et 100 patients with diverticulitis and generalized peritonitis patients with Hinchey disease required to an open was patient in the in case have been reported in the literature studies report their and it is unclear what of patients would have without any surgical The of patients for laparoscopic and its in to presentation between It has to be concluded therefore that the of laparoscopic and in the of treatment for acute diverticulitis is not the of data on laparoscopic for diverticular peritonitis, this approach is more commonly in this It an acute resection and in most patients. It however, whether an elective resection after from the acute should be recommended. In the series of 100 this was not generally undertaken and at follow up of only patients required resection The majority of the evidence for elective resection in diverticular disease is of poor The decision whether to resection should be made on an individual basis and the should involve the and in this in to the patients It is difficult to about the decision to elective resection because of the lack of data and on the of diverticulitis. surgery is or this can be due to the inflammation and The no of