Diverticulosis is an extremely common acquired disease among older Americans. One-third of those over age 45 and two-thirds of those over age 85 are thought to have diverticula in the colon wall. The actual prevalence is unclear because most diverticula are asymptomatic, according to the 2014 revised American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for sigmoid diverticulitis.
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The new ASCRS guidelines are based on growing evidence that diverticulitis may be a primary inflammatory process, rather than the result of microperforation (e.g., from eating nuts or popcorn) and bacterial infection. Moreover, only 13 to 23 percent of patients experience recurrence after acute uncomplicated diverticulitis, as opposed to prior estimates of 33 percent or more (see table).
A New View of Recurrence
“Surgeons used to tell patients, ‘If you don’t have elective surgery, the next attack could come with a vengeance, and you may need emergency surgery and a colostomy,’ ” says Feza H. Remzi, MD, Professor and Chair of Colorectal Surgery at Cleveland Clinic. “But that is not the case. I rarely have ever seen a mild to moderate diverticulitis present later as a perforation.”
Approximately 20 percent of individuals with diverticulosis develop at least one episode of diverticulitis. In the past, elective resection might have been recommended after a second or third recurrence. However, the number of attacks should not be a definitive decision point in uncomplicated diverticular disease. Instead, elective surgery decisions should be individualized, based on risk of recurrence, surgical morbidity, ongoing symptoms, disease complexity and operative risk.
Definition of ‘Old’ Has Changed
Dr. Remzi is adamant that age not be used as a cutoff for surgery. “More important factors are whether the patient can handle anesthesia and whether he or she is at high risk as a result of comorbidities,” he says. “The definition of ‘old’ has changed; many 75- to 80-year-olds have no significant major heart disease, COPD or frailty requiring use of a wheelchair.”
One study of 16,000 Medicare patients (mean age 78) concluded that most older adults do not require surgery or have recurrent attacks after a first diverticulitis episode. Those age 80 or older were least likely to experience a recurrence or require surgery, suggesting that the disease is relatively benign for them.
Patients Face Individual Decisions
Dr. Remzi believes that all patients, regardless of age, who experience acute uncomplicated diverticulitis should decide what makes sense for them based on their lifestyles and concerns about recurrence. He tells patients, “This is an individual decision. You need to understand that this attack may never come back ‒ or it may come back, but we don’t know when.”
A high-fiber diet might make more sense for people who usually remain geographically close to their physicians and quality medical care. Elective surgery might be the choice for those who travel far, who wish to eliminate the uncertainty of another acute episode or who experience the pain of frequent recurrences, he suggests.
Another study compared outcomes for 53,000 Medicare patients undergoing emergency versus elective surgery for diverticulitis. Mortality rates increased with age in both treatment groups, but the association between increasing age and morbidity, mortality and stoma formation was especially strong for patients who underwent elective colectomy.
Lower Risk with Laparoscopy
Dr. Remzi argues that laparoscopy changes the risk-benefit ratio for elective surgery for diverticulitis. Laparoscopy is associated with shorter hospital stays, lower morbidity and lower mortality than open surgery. The new ASCRS guidelines call for the laparoscopic approach “when expertise is available.” (Sigmoid colectomy with colorectal anastomosis is recommended.)
“Surgery done the right way prevents recurrence, and that means an experienced laparoscopic surgeon removing the whole sigmoid colon. If you leave a focus of sigmoid behind, the diverticulitis can come back,” says Dr. Remzi.
Of the 213 diverticulitis surgeries performed in 2013 by Cleveland Clinic colorectal surgeons, 62.4 percent were done via laparoscope, with a five-day median length of stay and a mortality rate of less than 1 percent.
Chance of Stoma Rises with Recurrence
Dr. Remzi cautions that “the more recurrences, the more complicated a laparoscopic procedure will be for both the patient and the surgeon, and the more likely that a stoma will be required.”
Patients with inflammation or infection may need a temporary loop ileostomy for three months; this differs from the permanent colostomy required by one-third of patients who undergo a Hartmann open procedure.
After elective surgery, changes in bowel habits are common for about three months and normalize in six months to a year. No postsurgical dietary restrictions are necessary.
Dr. Remzi, Professor and Chair of Colorectal Surgery in Cleveland Clinic’s Digestive Disease Institute, can be reached at 216.445.5020.