Managing Diverticulitis Without Surgery

Choosing surgery to remove part of the colon to treat severe diverticulitis may end patients’ symptoms, but like any surgical procedure, carries risks. Physicians who want to manage the disease without surgery also face the risk that patients could need an emergency colectomy.

In an article in Annals of Surgery, Debbi Li, MD and colleagues at the University of Toronto, Toronto, Ontario, Canada report on a retrospective study of 14,124 diverticulitis patients cared for without surgery. The research goal was to quantify the risks of readmission and emergency surgery when patients did not get a prophylactic colectomy.

The team found that over a 5-year period, 9% had to be readmitted to the hospital, 1.9% needed emergency surgery, and 14.1% died (a category that included all causes of death).

Younger patients (those under age 50) had a higher incidence of readmission than those who were older (10.5% vs. 8.4%), but the younger patients were slightly less likely to need emergency surgery (1.8% vs. 2.0%).

Patients with complications of diverticulitis such as abscess, fistula, and perforation were significantly more likely to need readmission (12.0%) than those with uncomplicated disease (8%).

All patients were Ontario residents age 18 or older admitted to the ER with a first episode of acute colonic diverticulitis. There were 18,543 such patients, and 78.5% were discharged alive without surgery.

Li and colleagues concluded that while some patients would return on an emergency basis, “the absolute risks of readmission and emergency surgery remain low even for patients with known risk factors and may not justify the risks associated with elective prophylactic colectomy.”

Complicated diverticulitis accounts for up to 30% of diverticulitis “yet little is known about the clinical course of patients with complicated disease managed without elective operation.” Patients with abscess usually require percutaneous draining of the infection, but usually get a colectomy later, Li wrote.

“However there is increasing evidence to suggest that percutaneous drainage alone may be sufficient treatment of complicated diverticulitis.”

These patients are at highest risk of needing emergency surgery immediately after hospital discharge, but that risk tapers off, she said. Even so, earlier studies have found that from 24% to 53% of these patients needing readmission, “the absolute risk of subsequent disease events in this study was much lower.” In the study, 85% of patients with complicated disease did not require readmissions, and more than 90% did not need emergency surgery.

The study did not attempt to determine the effects of not getting surgery had on patients’ quality of life. It is also possible that the researchers missed some complications due to diagnostic codes that did not link these events to an initial diagnosis of diverticulitis. That “might lead to an underestimation of complication rates during follow-up,” Li wrote. But she estimated that at least 84% of such complications linked to diverticulitis would have been captured in the data.

Another potential lapse in the data is that it did not include care that patients got in the outpatient setting without being admitted to the hospital. But since calculating readmission was the study goal, such data would not have altered its findings.