Risk of Emergency Surgery or Death After Initial Nonoperative Management of Complicated Diverticulitis in Scotland and Switzerland

Abstract

IMPORTANCE National guidelines on interval resection for prevention of recurrence after complicated diverticulitis are inconsistent. Although US and German guidelines favor interval colonic resection to prevent a perceived high risk of recurrence, UK guidelines do not.OBJECTIVES To investigate patient management and outcomes after an index inpatient episode of nonoperatively managed complicated diverticulitis in Switzerland and Scotland and determine whether interval resection was associated with the rate of disease-specific emergency surgery or death in either country. DESIGN, SETTING, AND PARTICIPANTSThis secondary analysis of anonymized complete national inpatient data sets included all patients with an inpatient episode of successfully nonoperatively managed complicated diverticulitis in Switzerland and Scotland from January 1, 2005, to December 31, 2015. The 2 countries have contrasting health care systems: Switzerland is insurance funded, while Scotland is state funded. Statistical analysis was conducted from February 1, 2018, to October 17, 2019. MAIN OUTCOMES AND MEASURESThe primary end point defined a priori before the analysis was adverse outcome, defined as any disease-specific emergency surgical intervention or inpatient death after the initial successful nonsurgical inpatient management of an episode of complicated diverticulitis, including complications from interval elective surgery. RESULTSThe study cohort comprised 13 861 inpatients in Switzerland (6967 women) and 5129 inpatients in Scotland (2804 women) with an index episode of complicated acute diverticulitis managed nonoperatively. The primary end point was observed in 698 Swiss patients (5.0%) and 255 Scottish patients (5.0%) (odds ratio, 0.98; 95% CI, 0.81-1.19). Elective interval colonic resection was undertaken in 3280 Swiss patients (23.7%; median follow-up, 53 months [interquartile range, 24-90 months]) and 231 Scottish patients (4.5%; median follow-up, 57 months [interquartile range, 27-91 months]). Death after urgent readmission for recurrent diverticulitis occurred in 104 patients (0.8%) in Switzerland and 65 patients (1.3%) in Scotland. None of the investigated confounders had a significant association with the outcome apart from comorbidity.CONCLUSIONS AND RELEVANCE This study found no difference in the rate of adverse outcome (emergency surgery and/or inpatient death) despite a 5-fold difference in interval resection rates.

AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review

“…[17][18][19] In an observational study, long-term rates of emergency surgery and/ or death were low (5%) among patients after an episode of complicated diverticulitis successfully managed without surgery. 55 Elective resection was not associated with reduced rates of emergency surgery or death.…”

Management of colonic diverticulitis

“…After successful non-operative treatment of complicated diverticulitis, the risk of recurrence requiring admission was 36% over 4.5 years of follow-up (fig 2). 29 In another cohort, the five year risk of diverticulitis recurrence requiring admission was 25%. Recurrence of complicated diverticulitis was low at 14%, and the risk of urgent colectomy was 8% 28.…”

“…Panel C: among patients with a diverticular abscess (Hinchey Ib/II diverticulitis), 48% have urgent or elective surgery within 6 months 28. Among patients with Hinchey Ib/II diverticulitis managed successfully without surgery, the risk of recurrence requiring admission is 25-36% over 5 years of follow-up 2829. Of patients with Hinchey Ib/II diverticulitis initially managed successfully without surgery, 5% will go on to have emergency surgery or to die from diverticulitis over 5 years of follow-up.…”

“…Of patients with Hinchey Ib/II diverticulitis initially managed successfully without surgery, 5% will go on to have emergency surgery or to die from diverticulitis over 5 years of follow-up. Interval elective resection does not decrease this risk 29. GI=gastrointestinal…”

Update on the management of sigmoid diverticulitis

“…A retrospective study of 142 patients with symptomatic disease who were treated with rifaximin noted a significant decrease in their symptoms including abdominal pain and tenderness[ 92 ]. A prospective randomized study of 165 patients, assigned to high fiber diet either with and without rifaximin, observed a 9% lower rate of recurrent diverticulitis on follow-up with addition of rifaximin[ 93 ]. Finally, a metanalysis of a total of 1660 patients found the combination of rifaximin and high fiber diet to be effective in secondary prevention with patients continuing to be symptom free at 1 year[ 50 ].…”