In late June, a group of surgeons from the United States and Europe published a comprehensive set of recommendations on managing acute diverticulitis—the first major effort to standardize diverticulitis care in two decades.
The 2019 document, which comprises 51 statements and 41 recommendations, demonstrates the evolution of acute diverticulitis care and reflects a collaborative approach to establishing evidence-based practice (Surg Endosc2019 Jul 27. [Epub ahead of print]). Developed and finalized over 18 months, the recommendations encompass a joint effort between two major endoscopic surgery societies: the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association of Endoscopic Surgery (EAES).
The 2019 publication represents “a major paradigm shift” in the management of acute diverticulitis, according to Steven D. Wexner, MD, PhD(Hon), FACS, who was not involved in developing the recommendations.
“This document offers exceptionally compelling evidence based on clinically relevant management parameters for a host of topics—such as when to operate, what type of surgery to perform, evidence-based antibiotic usage—all of which are based on a tremendously increased body of high-quality literature,” said Dr. Wexner, the chair of the Department of Colorectal Surgery and director of the Digestive Disease Center at Cleveland Clinic Florida, in Weston.
The 24-person team of experts crafted and graded statements and recommendations based on in-depth analyses of six key topics: the epidemiology, diagnosis and classification of acute diverticulitis; nonoperative management of uncomplicated and complicated acute disease; and operative management of emergency and elective cases. The experts then used the Delphi technique to reach consensus among themselves on each recommendation and statement.
“But the process was not just about a group of experts getting together to develop recommendations; it was also about achieving consensus among physicians more broadly,” said Patricia Sylla, MD, an associate professor of surgery in the Department of Colorectal Surgery at Icahn School of Medicine at Mount Sinai, in New York City, who led the project for SAGES. “That is why we sent surveys to members of SAGES and EAES and had live voting sessions at both 2018 meetings.”
Between March and May 2018, the team asked members of EAES and SAGES to complete a survey via email, which asked whether they agreed with each statement (yes/no) and whether the recommendation might alter their current practice (yes, no or already my current practice).
“What’s far more important than agreeing or disagreeing with a recommendation is whether it touches a person’s practice,” said Nader Francis, MBChB, PhD, a consultant colorectal surgeon at Yeovil District Hospital, in Somerset, England, and the project lead for EAES. “We could come up with the most amazing recommendations, but it won’t matter if people don’t follow them.”
After receiving more than 1,000 responses to the survey, the EAES and SAGES team found the majority of the 92 recommendations and statements received a high level of consensus—agreement from 70% or more respondents.
Five areas, however, proved more controversial. The committee presented these topics at the 2018 SAGES and EAES meetings and conducted a live revote. But before voting, the team reviewed the evidence that prompted the statements and fielded questions from attendees, with the aim of clarifying concerns and fostering consensus.
“During this process, we received another 300 votes, and were able to resolve some of the more controversial points,” Dr. Sylla said.
After a revote, one item—which stated that C-reactive protein (CRP) should be included in the laboratory evaluation of patients with acute diverticulitis—reached consensus on both the recommendation and likelihood to change practice.
But meeting attendees were less certain about a second recommendation, which proposed deferring or forgoing routine CT imaging in patients with suspected acute diverticulitis based on a physical exam and symptoms, including abdominal pain and high CRP levels. The revote reached consensus on the recommendation but not on its likelihood to change practice.
“I was not surprised by the lack of consensus on this topic,” Dr. Sylla said. “Currently, CRP is not routinely included on diagnostic tests in the [United States], and physicians may be hesitant to rely on a blood test over a CT scan. Also, fear of missing a diagnosis or liability from a medicolegal standpoint likely impacts patient care decisions, especially in the United States.”
The third point of controversy involved the role of interval endoscopy after an episode of acute diverticulitis. The experts recommended against routine colonic evaluation after treating uncomplicated acute diverticulitis unless high-risk features present. The revote reached consensus among EAES but not SAGES members, who agreed on the recommendation but not on the likelihood it would influence their practice.
“It’s very revealing to ask both questions,” Dr. Sylla said. “People can agree with a recommendation, but it doesn’t mean they will do something about it.”
Yet another point of controversy centered on the role of laparoscopic lavage, which has been a hotly contested topic for more than a decade. The recommendation that surgeons with appropriate expertise and the ability to manage complications may consider the technique in certain Hinchey III patients ultimately reached consensus during the live revote.
“The benefits of laparoscopic lavage are strong enough in the right setting, and the lower stoma rates associated with lavage should be weighed against the risk of complications,” Dr. Sylla said.
The most surprising finding, Dr. Sylla said, was on the use of antibiotics for uncomplicated acute diverticulitis. The recommendation stated that immunocompetent individuals presenting with uncomplicated acute diverticulitis do not require treatment with antibiotics. Recent studies have supported this practice, finding no difference in outcomes, complications or quality of life for these patients (Dis Colon Rectum 2019;62:608-614; Br J Surg 2017;104:52-61).
After listening to the evidence in support of the recommendation, EAES members reached consensus during the live revote. SAGES members, however, did not.
In this case, as with the routine use of CT scans, the discrepancy may come down to concerns over potential medicolegal consequences of forgoing antibiotics or showcase physician and patient preferences that are difficult to change.
“I think quite simply that Europe doesn’t have the same medicolegal issues we face in the [United States],” Dr. Wexner said. “American patients may well expect antibiotics while European patients may not.”
The Evolution of Care
In a recent editorial, Dr. Wexner reflected on how far the field has come in its understanding of acute diverticulitis and our ability to treat it (Surg Endosc2019;33: 2724-2725).
One key issue only addressed in the 2019 consensus is the role of bowel preparation before surgery. Although the evidence specific to diverticular disease is limited, the committee recommended mechanical bowel preparation with oral antibiotics before surgery, given the lower rates of surgical site infections and anastomotic leaks associated with the practice.
“For this recommendation, I believe the pendulum has swung from the traditional combination of oral and mechanical antibiotic bowel preparation to no preparation and now back to the original recommendation,” Dr. Wexner said.
The 2019 document also discourages elective surgery simply to avoid future episodes, instead recommending a tailored approach to care. The 1999 guidelines, on the other hand, state that patients should be considered for elective surgery following at least two attacks.
“We’ve evolved to an individualized treatment which overall favors less invasive therapies,” Dr. Wexner said.
But, he said, “the biggest shift in the diverticulitis recommendations is reflected in the use of minimally invasive surgery.”
The 1999 guidelines were derived from the early days of laparoscopic surgery when surgeons did not have the technological tools or technical capabilities that currently exist. “What we now describe as ‘laparoscopic’ surgery isn’t what we called it in the 1990s,” Dr. Wexner said. “In 1999, the discussion focused on whether or not to use laparoscopy, but since then minimally invasive surgery has dramatically evolved.”
The 1999 guidelines stated that “laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing” (Surg Endosc1999;13:430-436).
“In the context of our knowledge and capabilities in the 1990s, that statement was appropriate, but it is only of historical interest in stark contrast to the 2019 publication,” Dr. Wexner said.
The current recommendations state, for instance, that “laparoscopy is safe in the setting of elective surgery for diverticulitis and is associated with reduced rates of morbidity and length of stay compared to open surgery” and encourage this approach for “elective surgery for diverticular disease, when feasible” and “for perforated diverticulitis in the appropriate clinical setting.”
Considering the prevalence and permanence of this condition as well as the cost of treatment, Dr. Francis stressed the importance of having standardized and robust guidance for physicians.
“These recommendations provide strong support for clinicians,” Dr. Francis said. “Instead of institutions working in silos, we hope the recommendations bring everyone together on best practices and help protect both patients and clinicians.”
Dr. Francis also noted that the success of this collaboration has paved the way for future ones. “EAES and SAGES are already working together on new GERD recommendations,” he said.