Traditional approaches to managing uncomplicated diverticulitis have been displaced to a degree in recent years by more evidence-based treatment strategies, with options that feature an enhanced focus on individualized patient care.
In the Panel Session, “The Ever-Shifting Paradigm in the Treatment of Diverticulitis,” on Sunday morning, panelists cited up-to-date clinical studies examining the various management pathways for diverticular disease, particularly options that continue to fuel debate among surgeons.
Specifically, presenters explored:
- Recent quality-of-life data that can guide shared decision-making regarding elective colectomy for diverticular disease
- Indications for operative intervention for immunosuppressed patients
- Considerations for a Hartmann procedure in the context of new data supporting the use of primary anastomosis with fecal diversion
- How the gut microbiome may contribute to the pathogenesis of diverticular disease
Nonoperative management can be safe and feasible for specific immunocompromised patients with colonic diverticulitis, according to Nitin Mishra, MBBS, FACS, who advised clinicians to consider both the type of immunosuppression (intrinsic or extrinsic) and duration (temporary or permanent).
As for the role of the gut microbiome as a driver for diverticulitis, Benjamin Shogan, MD, FACS, cited several recent studies that suggest both clinical and symptom scores are significantly correlated with fecal microbiota features in patients with diverticular disease.
“The conclusion that I've come up with is that, in patients with a history of uncomplicated diverticulitis, they have decreased short-chain fatty acid-producing bacteria, decreased anti-inflammatory bacteria, and an increase in mucin-degrading bacteria,” he said, adding that advances in this clinical niche area could lead to uncovering new targets for intervention.
“Presenters also highlighted areas where exciting new research has the capacity to impact how we treat patients in specific scenarios on a day-to-day basis in practice,” said Jennifer S. Davids, MD, FACS, session moderator. “For example, quality of life is a key factor in the shared decision-making between surgeons and patients considering elective surgery for diverticulitis. Recent trials have compared the impact of surgery to standard nonoperative treatment in terms of quality of life, and this can be extrapolated to patients seen in the clinic.”
Factors influencing quality of life for patients with diverticulitis include severity of symptoms, hospitalization/interventions, frequency of attacks, symptoms between attacks, and fear of future attacks, explained Emily Steinhagen, MD, FACS.
“The data suggest that surgery improves quality of life for most patients who have diverticular disease, particularly those who have quality of life that's decreased by their symptoms,” said Dr. Steinhagen. “But the key to doing it is having realistic expectations and partnering with our patients in true shared decision-making.”
Surgeons who care for patients suffering from diverticular disease should develop a keen understanding that “one size-fits all” is a dated approach.
According to co-moderator Brian R. Kann, MD, FACS: “As we learn more about the etiology, pathogenesis, and management of diverticular disease, we are finding that many of the treatment principles that have been held as ‘surgical dogma’ for years may not hold true any longer. As our understanding of this disease evolves, so must our approach to treating our patients.”
