Expert Panel Discusses the Latest in Diverticulitis Management Strategies

Management strategies for patients with diverticulitis have become increasingly individualized over the past five years as new evidence emerged, leading to improved outcomes for patients, but also adding new challenges for surgeons and other physicians who care for them.

There is a growing gap between evidence-based practice in diverticulitis and the care provided to patients, according to a panel at the 2023 Clinical Congress of the American College of Surgeons. Surgeons packed the room to hear the latest research guiding treatment of diverticulitis for different patient groups.

Antibiotics Still Overused in Diverticulitis

Marylise Boutros, MD, a colorectal surgeon at Cleveland Clinic Florida, in Weston, urged surgeons to take a leadership role in ending the long-time practice of routinely prescribing antibiotics for patients with uncomplicated diverticulitis. Studies, mostly from Europe, show that most patients do not need antibiotics for uncomplicated acute diverticulitis (Br J Surg 2012;99[4]:532-539; Br J Surg 2019;106[11]:1542-1548; Br J Surg 2017;104[1]:52-61).

“I would say look for a reason to give antibiotics rather than to avoid antibiotics,” Dr. Boutros said.

Patients typically receive antibiotics early after a diagnosis of uncomplicated diverticulitis—often before they see a surgeon, if they see one at all for mild diverticulitis, she noted. But surgeons can still help change treatment patterns by educating colleagues and patients about the lack of benefit from antibiotics in most patients, she said.

“I believe that we are the champions of diverticulitis, and we need to take the onus on us to spread information,” she said.

Two national surgical societies—the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS)—now recommend non-antibiotic therapy for patients with uncomplicated diverticulitis. In addition, a 2022 Cochrane Review found that there is no clear benefit from antibiotics for complications, emergency surgery, recurrence, elective colonic resections or long-term complications, although the quality of evidence is low (Cochrane Database Syst Rev 2022;6[6]:CD009092).

But many surgeons and other physicians remain reluctant to skip antibiotics in diverticulitis patients, driven by concerns about insufficient evidence, lack of North American data, concern for patient outcomes, medicolegal ramifications and long-time surgical dogma, Dr. Boutros said. In a 2017 study of Irish surgeons, only one in five said they would consider not using antibiotics (Surgeon 2017;15[4]:206-210).

She encouraged surgeons to lead changes in their hospitals. SAGES is also planning a campaign to help educate surgeons, primary care physicians, emergency physicians and other healthcare workers about the risk of overuse of antibiotics in uncomplicated diverticulitis, she added.

“The first step is we need to implement locally, and then we’ll scale up and hopefully will spread widely.”

PAPD Slowly Gaining Steam For Diverticulitis

The shift away from antibiotics is happening quickly compared with the glacial pace of change in surgical technique, said Robert N. Goldstone, MD, an assistant professor of surgery at Harvard Medical School, in Boston.

Hartmann’s procedure, which turned 100 this year, remains the dominant surgical approach for diverticulitis in the United States. As late as 2017, 93% of patients in this country who underwent surgery within 48 hours of admission for diverticulitis had a Hartmann’s procedure (JAMA Netw Open 2021;4[11]:e2130674).

But primary anastomosis with or without proximal diversion (PAPD) is an acceptable procedure in many patients who are suitable candidates for surgery, which was established by studies dating back to 2012. The 2019 LADIES trial, which randomized 130 patients from 28 hospitals in Belgium, Italy and the Netherlands, found no difference in mortality or morbidity between the two approaches, but patients who had a PAPD were significantly more likely to have stoma reversal within 12 months, at 87.3% compared with 68.2% (Lancet Gastroenterol Hepatol 2019;4[8]:599-610).

The decision to proceed with PAPD or Hartmann’s should be individualized based on a patient’s perioperative risk and their surgeon’s comfort with the procedure, Dr. Goldstone said. “You really have to consider yourself and how you feel about doing this procedure as well as the patient’s clinical status at the time of surgery.”

The move away from Hartmann’s is increasing slowly, nudged by a growing body of evidence and an uptick in colorectal surgeons who are operating on diverticulitis patients. From 2014 to 2017, the rate of PAPD increased rapidly from 2.6% to 7.1%, a pattern that overlapped with more colorectal surgeons performing these operations (JAMA Netw Open 2021;4[11]:e2130674s).

In 2020, the ASCRS, in a new guideline, recommended that patient factors, intraoperative factors and surgeon preference be taken into account following resection in the decision to restore bowel continuity. The recommendation was based on moderate-quality evidence.

Studies cannot always account for intraoperative factors like hemodynamic status, Dr. Goldstone cautioned. Some major studies of PAPD for diverticulitis do not include higher risk patients. The LADIES trial, for instance, did not include patients on inotropes or steroids. Furthermore, PAPD is a longer operation, which can be significant when patients are in septic shock.

Patients with immunocompromised status are less likely to be good candidates for PAPD, Dr. Goldstone noted. They have higher risks for anastomotic leak, especially those taking steroids, and their quality of life at baseline needs to be considered. “Are these patients incontinent at baseline? Are they bed-bound?” he said. “Would it be an improved quality of life to have an end colostomy as opposed to a primary anastomosis?”

He stressed that patient safety must be the top priority. “Quality of life and morbidity of secondary operations only apply to those who survived the initial endeavor,” he said.

The Challenge of Immunocompromised Patients

Immunocompromised patients are more likely to develop diverticulitis than the general population, and they are particularly challenging to diagnose and treat, said Dana M. Hayden, MD, MPH, a professor of surgery at the University of Wisconsin, in Madison. The symptoms of diverticulitis are sometimes masked by patients’ other conditions or their medications, leading to a delayed diagnosis. In addition, patients often have an impaired ability to fight infection or the complications of diverticulitis.

There is no one-size-fits-all approach to managing diverticulitis in this population due to the differing types and spectrums of immune suppression, Dr. Hayden said.

For all patients, healthcare workers first need to establish the correct diagnosis and start appropriate treatment promptly, she added. CT remains the standard for guiding treatment, she said.

Nonoperative management is feasible in some immunocompromised patients, especially for uncomplicated diverticulitis. But when their disease is complicated or severe, immunosuppressed patients have a higher need for emergency surgery. They also have higher rates of mortality with emergency surgery.

Outcomes vary for different populations of immunosuppressed patients. Liver and kidney transplant patients tend to have better outcomes with surgery and nonoperative management than patients awaiting transplant (Can J Surg 2016;59[4]:254-261). A 2016 study showed that HIV patients with diverticulitis have an increased in-hospital mortality rate and a lower rate of surgical intervention compared with patients without HIV, and that diverticulitis is increasing in prevalence among HIV-infected patients (HIV Med 2016;17[3]:216-221).

People receiving steroid treatment tend to have the worst outcomes in the immunosuppressed population, with studies showing a higher rate of perforation and recurrence. A large Danish study of 3,148 patients with acute diverticulitis with abscess formation showed that those taking steroids before admission had higher mortality, regardless of whether they received antibiotics, drainage or operative treatment (Int J Colorectal Dis 2018;33[4]:431-440). “Steroids seem to be the worst culprit,” Dr. Hayden said.

Patients who received chemotherapy within one month of a diverticulitis episode did not have increased perioperative morbidity and mortality, but they were more likely to develop a postoperative complication after interval resection, according to a 2014 study (Int J Surg 2014;12[12]:1489-1494). The authors concluded that the data do not support elective surgery for acute diverticulitis for patients receiving chemotherapy.

Studies have drawn mixed conclusions about the effect of diabetes on diverticulitis outcomes. In a study of 1,019 patients admitted with diverticulitis, 164 patients with diabetes had no significant difference in the failure of nonoperative management, readmissions or death, but they were more likely to have acute renal failure or infectious complications after surgery (J Trauma Acute Care Surg 2014;76[3]:704-709). A 2022 study found that the main driver of diverticulitis in diabetes patients is body mass index, and that patients with a longer duration of diabetes were less likely to have diverticulitis, perhaps due to their use of metformin (BMJ Open 2022;12:e059852).

A number of large recent studies looked at outcomes of acute diverticulitis across immunocompromised patients and showed higher rates of surgery and complications during emergency surgery. In an international study of 482 patients with acute diverticulitis, immunocompromised patients with acute diverticulitis presented with a more severe clinical picture, and they had higher rates of postoperative morbidity and mortality than other patients with diverticulitis (Tech Coloproctol 2023;27[9]:747-757). And a 2021 meta-analysis of 11 studies of 2,977 immunosuppressed patients and 780,630 immune-competent patients showed that mortality was greater for immunosuppressed patients having emergency surgery but not elective surgery (Am J Surg 2021;221[1]:72-85).

Dr. Hayden recommended that surgeons consider elective surgery in patients who initially have nonoperative management but are at high risk for recurrence. They should aim to do surgery within the first six months if patients had a severe index case, she added.

“Recurrence can be more severe and have worse outcomes if we didn’t get to that patient in time. But you also must balance this with complications during the elective resection for immune-suppressed patients,” Dr. Hayden said.

Racial Disparities in Diverticulitis

A study published in 2023, from researchers at Harbor-UCLA, found that Black patients and, especially, Native Hawaiian/Pacific Islanders with diverticulitis face significantly increased mortality and morbidity, even though the analysis found that the racial gap in access to laparoscopy has closed (J Surg Res 2023;283:889-897). In this study, in Native Hawaiian/Pacific Islanders—who are often left out of studies of racial disparities in healthcare or lumped in with other groups—the mortality rate was an astonishing 5.3 times higher than in white patients. Black race was independently associated with a 24% increase in 30-day morbidity.

“The racial disparity in diverticulitis management is an ongoing battle for us,” said Hanjoo Lee, MD, a colorectal surgeon at Harbor-UCLA Medical Center, in Los Angeles, and a co-author of the study. “It’s a difficult process. It’s a long process.”

Studies showed racial disparities in diverticulitis outcomes more than a decade ago, particularly for Black patients, and these included gaps in mortality, rates of surgery and complications related to diverticulitis. But the gaps are often the result of multiple, connected factors that begin before someone develops diverticulitis, he said. “It often manifests in the preoperative setting, even prior to presenting to our clinics in emergency settings. The unequal access and unequal treatments and unequal disease are intimately related to each other.”

Dr. Lee said the factors that lead to poorer outcomes include findings that Black patients were more likely to present to smaller, less well-staffed hospitals; they are less likely to have a family physician as their point of primary care; they are less likely to undergo laparoscopic surgery; and they have less access to colorectal surgeons.

He said collaborative efforts between government agencies and private enterprises are needed to close the gap.

“The disparity in access to care entails a complex interplay between socioeconomic, geographical, demographic and disease factors,” he said.