The Indications for and Timing of Surgery for Diverticular Disease

Abstract

Background: Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease.

Methods: This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease.

Results: Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails.

Conclusion: The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

eFigure 1

PRISMA diagram of article selection This data analysis and recommendations derived from it were presented and discussed during 3 meetings of the DGAV Quality Commission. The Oxford criteria (version 2011) were used for evidence rating. The final recommendations were presented to the members of the quality commission and subsequently adopted in an open vote with strong consensus (>95% of participants consented). The identified 1577 abstracts of studies, guidelines and reviews were independently screened by four authors (JPR, TS, CR, CTG) and subsequently 132 full-text articles were reviewed (Endnote X9, Clarivate Analytics, Boston, USA). After selection of the articles based on their relevance for the indication for surgery, finally 38 original articles, 12 systematic reviews and meta-analyses and 10 national and international guidelines were selected and analyzed. Based on the results of this analysis, recommendations for the indications for surgery were drawn up. This data analysis and recommendations derived from it were presented and discussed in 3 meetings of the DGAV Quality Commission. The Oxford criteria (version 2011) were used for evidence rating. The final recommendations were presented to the members of the DGAV quality commission and subsequently adopted in an open vote with strong consensus (>95% of participants agreed).