When Should Surgery Be Considered for Patients With Recurrent Diverticulitis?

Q: When should surgery be considered for patients with recurrent diverticulitis?

A: We’ve seen a significant change in our approach to surgery for diverticulitis in the United States, particularly over the past decade.

When I came here almost 20 years ago from Ireland, I was surprised to see the frequency of diverticulitis surgery here, often done in younger patients after a single attack. In Europe it tended to be managed much more conservatively. It’s been very interesting to note that as more evidence has accumulated (including data based on Medicare population analysis from Dr. David Flum and others), the suggested threshold for when the risk of death and colostomy for simple diverticulitis is less with surgery than with observation is four attacks.

The most important thing, however, is how we manage the individual patient. There are always patients who are seen emergently with peritonitis from a local perforation. These generally need a trip to the operating room. And the most traditional management is resection, choosing patients for primary anastomosis with or without diversion, or end colostomy, based on the degree of peritoneal contamination. I also personally think one of the key components of making a decision about anastomosis is the quality of the rectal stump, as it is sometimes so thickened and inflamed that an anastomosis may not be advised.

Over the past five to 10 years, there has also been lots of discussion about laparoscopic lavage. This has been studied in a number of randomized, controlled trials and it appears that patients who have laparoscopic lavage are more likely to need subsequent intervention. However, this is often radiological in nature and patients can sometimes avoid surgery and colostomy. Whilst our understanding of the exact role of laparoscopic lavage needs to evolve a little further, there are certainly some patients for whom this is a good option.

Of course, the majority of patients we see are for management of recurrent episodes of diverticulitis. Even though we often discuss the number of attacks, the frequency and severity of these attacks is also critical. If someone has three attacks six weeks apart, this is a very different decision-making algorithm than for someone who has three attacks, each a decade apart. In addition, the frailty and lifestyle of the patient also affect decision-making. If a patient is a frail 85-year-old who had a fourth mild attack, but the last attack was 10 years ago, they are unlikely to need surgery.

At the end of the day, the most important thing is to give the patient an informed understanding of the literature and make the best recommendation that you can for their individual situation.

When choosing a surgical approach, I believe almost all of us would now favor a minimally invasive laparoscopic approach. This is safe and effective when dealing with recurrent diverticular disease, acute presentation, as well as management of complications such as fistula and obstruction. We are fortunate to be able to offer this to our patients to give them an easier recovery after surgery and reduce their chances of having complications.

Conor Delaney, MD, PhD
Chairman, Digestive Disease & Surgery Institute
Cleveland Clinic