Laparoscopic sigmoid resection for recurrent diverticulitis associated with higher quality of life scores

1. Patients with recurrent diverticulitis have higher quality of life scores after undergoing elective laparoscopic sigmoid resection, compared to a conservative treatment.

2. Elective surgery was associated with a 10% complication rate.

Evidence Rating Level: 1 (Excellent)

Study rundown: Diverticular disease ranges in presentation from acute diverticulitis that can be mild and uncomplicated to perforation leading to life-threatening peritonitis. Because the first episode is often the most severe and recurrences rarely require emergency surgery, current guidelines recommend a conservative approach, without removing the affected bowel portion. However, quality of life (QOL) is negatively impacted by recurrent diverticulitis, and an elective laparoscopic sigmoid resection procedure could potentially ameliorate QOL. The current study was a randomized controlled trial comparing 6-month QOL outcomes in patients receiving this procedure versus receiving a conservative approach to treatment. QOL was measured using the Gastrointestinal Quality of Life Index, a 144-point questionnaire where severity of GI symptoms are rated on a 4 point scale (less severity is equivalent to higher points). 6 months after randomization, the GIQLI score was on average 11.96 points higher in the surgery group than the conservative treatment. Additionally, patients who received conservative treatment had higher recurrence rates, and reported pain more frequently than in the surgery group. However, there was a Grade III complication rate of 10% in the surgery group: two patients developed abscesses which required percutaneous drainage and two patients with anastomotic leakages that required reoperation. Nonetheless, due to the significant QOL benefit, the study was terminated early. Overall, this study demonstrated that there is increased QOL for patients undergoing elective sigmoid resection compared to conservative management, although there is a risk of experiencing post-operative complications. Of note, the study population did have various indications for surgery as well, including recurrent diverticulitis, so these results may not be representative of patients presenting less severely. Further studies recruiting a larger population and introducing blinding of the patients (ie sham surgery) may also clarify these findings.

Click here to read the study in JAMA Surgery

Relevant Reading: Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial

In-Depth [randomized controlled trial]: The study population consisted of 85 patients (31% male), with a mean [SD] age of 53.62 [11.90] and 57.08 [7.68] for males and females, respectively.  Forty-one patients were allocated to the surgery group and 44 in the conservative treatment. Surgeries were scheduled 3 months after randomization, conducted at 2 academic and 3 community hospitals in Finland. Only patients with three episodes of diverticulitis in the past two years were included in the study. Overall, the results showed an average of 11.96 higher GIQLI scores in the surgery group compared to the conservative treatment group (95% CI 3.72-20.19, p = 0.005). Furthermore, 5% in the surgery group experienced a recurrence of diverticulitis (compared to 27% in the conservative group) and 46% reported pain at 6 months (compared to 68%). However, the surgery group had a 10% rate of Clavien-Dindo grade III complications, which included postoperative abscesses (5%) and anastomotic leakages (5%).

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