Colectomy isn't always indicated for recurrent diverticulitis

By Rob Goodier

NEW YORK (Reuters Health) - Surgery may be indicated in fewer cases of diverticulitis than previously thought, according to a recent literature review.

Rather than performing surgery as a blanket response to recurrent episodes, physicians should make the decision based on risk factors that are specific to each patient, the review suggests. In that, it agrees with current guidelines.

And, while surgery is recommended in cases of complicated, perforated acute disease, the new evidence suggests that in the absence of sepsis, non-invasive treatment may succeed.

The evidence appears in a review of 68 studies published online in JAMA Surgery January 15 by Dr. Arden Morris and a research team at the University of Michigan in Ann Arbor.

Among the findings, the number of recurrences, as long as there have been two or more, does not increase the risk for complications. The patient's age may not increase that risk, either, although younger patients may be at higher risk for recurrences.

In keeping with those findings, patients who are only at average risk for complications do not need prophylactic surgery, regardless of the number of recurrences they have suffered. But only as long as the recurrences were not complicated, the review finds.

"Patients may pursue an operation out of fear of emergency colectomy resulting in colostomy. However, the likelihood of such an event after an uncomplicated episode of diverticulitis in average-risk patients is quite low," Dr. Morris and his team write.

Patients often do require surgery in cases of perforation, fistula and stricture, the researchers write.

Other findings include that there may be only a few cases, less than 5%, in which a complicated recurrence follows an uncomplicated episode.

Also, resection may not cure chronic symptoms in all patients. Five to 22% of patients continue to experience symptoms even after surgery.

Dr. Morris was unavailable for comment.

But Dr. Matt Bailey, from the University of Kentucky's Department of General Surgery, who was not involved in the research, offered comments in consultation with Dr. David Vargas, head of his university's Colon and Rectal Surgery section.

"We think it's worth emphasizing the importance of considering an anastomosis at the original operation. Approximately half of all patients that undergo a Hartmann's procedure may never attempt reversal with significant morbidity associated with a closure of a Hartmann's procedure. Although not every patient is appropriate for an anastomosis at the time of index operation, a Hartmann's procedure should not be taken lightly as something that will be easily reversed in the future," Dr. Bailey told Reuters Health in an email.

"Beyond the steadfast indications for colectomy, such as sepsis with diffuse peritonitis or failure of non-operative management, we agree the decision for elective resection should be considered on a case-by-case basis - after a discussion of how the disease affects the patient's life, risk of recurrence, post-operative expectations, and operative risk."

SOURCE: http://bit.ly/1g1iSJL

JAMA Surgery 2014.

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