At what point is surgery indicated for recurrent diverticulitis (inflammatory disease of the diverticula)?

From the Guidelines

Surgery for recurrent diverticulitis is indicated on a case-by-case basis, considering factors such as the severity of disease, patient preferences and values, as well as risks and benefits, including quality of life, rather than solely on the number of episodes of diverticulitis. The decision to recommend elective resection should include a discussion of the patient’s comorbidities, severity of diverticulitis, patient preferences and values, as well as operative risks and benefits 1. Elective sigmoid colectomy is the standard surgical approach, which can be performed laparoscopically in many cases.

Key Considerations

• The frequency and severity of attacks, impact on quality of life, and the patient's overall health status should be considered when deciding on surgery 1.
• Patients with chronic symptoms or those who cannot tolerate multiple courses of antibiotics may benefit from earlier surgical intervention 1.
• Immunocompromised patients are at higher risk of complicated recurrence and may benefit from elective resection 1.
• The rationale for surgery is to prevent future episodes and complications, as each recurrence increases the risk of complications and emergency surgery, which carries higher morbidity and mortality rates than elective procedures.

Surgical Approach

• Elective sigmoid colectomy is the standard surgical approach, which can be performed laparoscopically in many cases.
• The decision for surgery should be personalized and consider the patient's individual circumstances and comorbidities.

Recent Guidelines

• The American College of Physicians (ACP) suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis 1.
• The World Society of Emergency Surgery (WSES) suggests evaluating patient-related factors and not the number of previous episodes of diverticulitis in planning elective sigmoid resection 1.

From the Research

Indications for Surgery in Recurrent Diverticulitis

• The decision to proceed with surgery for recurrent diverticulitis should be based on the patient-reported frequency and severity of diverticulitis symptoms, rather than the number of episodes of acute, noncomplicated disease 2.
• Complicated recurrence after recovery from an uncomplicated episode of diverticulitis is rare (<5%), and age at onset younger than 50 years and 2 or more recurrences do not increase the risk of complications 2.
• Some studies suggest that patients with recurrent uncomplicated diverticulitis should be operated on after two documented episodes to reduce the symptoms of the patients 3.
• However, the absolute number of previous episodes is not used as criteria to recommend surgery anymore, and young age is no longer considered to be an indication for more aggressive surgical treatment 4.
• Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available, and the decision to perform sigmoid colectomy should be individualized, after careful risk-benefit assessment 4.

Factors Influencing the Decision for Surgery

• The presence of chronic symptoms, the complexity of disease, and operative risk should be considered when deciding to proceed with colectomy 2.
• Patients with a preoperative diagnosis of irritable bowel syndrome (IBS), diverticulitis involving the descending colon, and a long-lasting disease are more likely to have recurrent diverticulitis 5.
• The need for treatment by a physician, the need for hospital treatment, the presence of abdominal cramps, the presence of febrile left lower abdominal pain, the need for antibiotics, and the need for NSAIDs are more common in patients treated non-operatively for recurrent diverticulitis 3.

Current Recommendations

• Prophylactic surgery is generally not recommended for average-risk patients with diverticulitis, irrespective of the number of episodes of acute, noncomplicated disease 2.
• The use of antibiotics in uncomplicated diverticulitis is questionable, and the evidence on antibiotic treatment suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 6.