Elective Surgery for Diverticulitis Led to QOL Benefits, Fewer Recurrences

Elective sigmoid resection for patients with recurrent, complicated, or persistent painful diverticulitis yielded a better quality of life and prevented recurrences compared with nonsurgical conservative care, a 2-year analysis of the randomized LASER trial showed.

Among 85 patients in the intention-to-treat analyses, the mean Gastrointestinal Quality of Life Index (GIQLI) score was 9.51 points higher in the surgery group versus the conservative group at 1 year (mean 118.54 vs 109.03; P=0.03), though this score was similar at 2 years, reported Ville Sallinen, MD, PhD, of the University of Helsinki and Helsinki University Hospital in Finland, and colleagues.

Also within 2 years, 61% of patients in the conservative group had recurrent diverticulitis compared with 11% of patients in the surgery group, they noted in JAMA Surgery.

"These results add to the growing evidence that surgery is beneficial for patients with frequently recurring diverticulitis, and the benefit lasts several years," Sallinen wrote in an email to MedPage Today. "The conservative treatment was also safe, but surgery was really effective in preventing the recurrences."

Ten percent of the patients in the surgery group had major postoperative complications compared with 5% of the conservative group (18% of the patients in the conservative group ended up undergoing surgery within 2 years). In per-protocol analyses, mean GIQLI scores were higher in the surgery group at both 1 and 2 years, but these analyses excluded the conservative group patients who underwent surgery.

"Looking at everybody who got the surgery, in the end, the outcomes are improved," said Jennifer S. Davids, MD, of the Boston University Chobanian & Avedisian School of Medicine, who wrote an invited commentary for the study along with Susanna S. Hill, MD, MSCI, of the University of Minnesota in Minneapolis.

"So when weighing the morbidity and chronic issues and challenges with having recurrent episodes of diverticulitis against the potential small risks of surgery, I think that this trial supports the fact that quality of life may be improved for patients that undergo surgery," she told MedPage Today.

"I think the fact that it was randomized is very admirable, and therefore I think the results can be really translated a little bit better into practice," she added.

In their commentary, Davids and Hill wrote, "it is critical that we continue to perform further study with [randomized clinical trials] in the context of benign disease to provide the most informed surgical decision-making."

Risks of surgery for diverticulitis can be serious, and physicians must weigh them against benefits in a decision-making process with their patient. "The most feared complication of this type of surgery is what's called the anastomotic leak ... [which can] ultimately lead to either a colostomy or an ileostomy," Davids said. "So that is what gives people pause before considering undergoing elective surgery for diverticulitis."

She noted that the risk for a stoma in this study was 5% in the surgery group, about what you'd expect.

Research on benefits, however, has been scarce, according to both the study authors and Davids. "We see many such patients in our outpatient clinics, and we were unable to give strong recommendation whether it would be beneficial to proceed to sigmoid resection or continue conservative treatment," Sallinen said. A similar recent trial, called DIRECT, found a similar difference at 1 year between quality of life scores, favoring surgery over conservative treatment.

"If the patient has good quality of life with conservative treatment, that can be continued. However, if the quality of life is impaired due to frequently recurring diverticulitis, surgery is a good option and will improve quality of life," Sallinen continued.

His study used three or more episodes of left colon diverticulitis within a 2-year period as eligibility criteria. "These figures can be used in clinical practice as a threshold for offering sigmoid resection in these patients," Sallinen said.

For this study, patients were recruited from five hospitals in Finland from September 2014 to October 2018. Of the 85 patients randomized, 75 and 70 were available for quality of life outcomes at 1 year and 2 years, respectively, and 79 and 78 were available for the recurrence outcome at 1 year and 2 years.

Women, with a mean age of 57, made up 69% of the study sample. Mean age among the men was 54.

Those receiving conservative treatment were given standardized written information about diverticulosis and constipation, were advised to increase their fiber intake, and were prescribed fiber supplements. They were allowed to undergo elective sigmoid resection after 6 months if desired.

Limitations to the study included early termination for benefit, a small sample size due to the difficulty in recruiting patients, and the heterogeneity of the study population, which combined patients with different kinds of diverticulitis.

"This broad range of symptomatology and small sample size precludes our ability to draw conclusions about outcome based on disease presentation, which is key to patient counseling," Davids and Hill wrote.

Sallinen and team also noted that missing quality of life questionnaires could have introduced bias, and that outcomes reported at 2 years could change with longer follow-up.

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