Elective surgery for conservatively treated acute uncomplicated diverticulitis: a systematic review of postoperative outcomes

Abstract

Introduction: Elective surgery has been proposed, after at least two episodes of acute diverticulitis, initially treated conservatively, in order to prevent further episodes or chronic complaints. However, prophylactic surgery has been questioned, due to the associated risks of postoperative mortality and morbidity, as well as the risk of recurrent diverticulitis. This systematic review attempts to assess the role of prophylactic left colonic resection, after episodes of uncomplicated acute diverticulitis treated either conservatively with antibiotics and/or other supportive measures.

Evidence acquisition: A systematic search was performed using Medline, Embase, Ovid, and Cochrane databases for studies reporting on the treatment of acute uncomplicated diverticulitis (Hinchey I). The main endpoint was treatment failure, defined as persistent/recurrent symptoms or need for readmission and/or reintervention. Secondary endpoints were the immediate postoperative outcomes.

Evidence synthesis: In total, 24 studies with 2855 patients were included in the analysis. Intra- and postoperative complications rate were 5% and 16%, respectively. Anastomotic leak was 1.3% and emergency reoperation was 2.4%. Long-term symptomatic resolve was reported at 91%. Persistent or recurrent symptoms were observed in 5.4% of cases. Meta-analysis showed no significant difference in recurrence rates between surgical and conservative management.

Conclusions: Elective surgery to prevent recurrent diverticulitis is not recommended, irrespective of the number of previous episodes. Generally, elective sigmoidectomy should not be recommended to patients with ongoing atypical lower abdominal symptoms after acute diverticulitis, but should aim primarily at improving quality of life. It should be offered to patients with ongoing inflammation, or diverticular complications.