Professor Tom Øresland (Akershus University Hospital, Norway) discussed the management of complicated diverticulitis at this year’s ESCP meeting in Milan. We talked to Professor Oresland about the current treatment strategies for this condition and other issues…
The incidence of diverticulosis is increasingly common and its prevalence increases with age, and Professor Øresland estimated that 50% of people over aged 50 or will harbour diverticulas in their colon. Of these, some 20% will have symptoms, meaning 10% of the population will have symptoms of the condition at some point in their lifetime. Moreover, it is estimated diverticula will affect approximately 70% of individuals by age 80 [1]. Despite this, Professor Øresland said that very little is known about the aetiology of the disease.
"We know that a poor low-fibre diet does contribute to the development of diverticular disease, as the lack of fibre leads to an increase in intraluminal pressure in the bowel," he explained. "This promotes herniation and the collagen in the bowel wall contributes to its development. There are also likely to be genetic and other factors, which mean some patients will develop the disease despite having a high-fibre diet."
The 'Diverticulitis' session in Milan will feature three presentations on the management of non-complicated diverticulitis (Nikolas Gouvas, Greece), the management of complicated diverticulitis (Tom Øresland, Norway) and the indications for elective surgery (Patricia Roberts, USA).
He explained that there are the four main treatment options for complicated diverticulitis – antibiotics either alone or combined with, laparoscopic lavage, resection of the diseased segment of the bowel and a primary anastomosis, and resection with a stoma.
"In my presentation, I will discuss the acute complications, the different options of treating acute diverticulitis available. I will also talk about perforated diverticulitis and managing bacteria that is on the outside of the bowel," he added. "It is not exactly clear when to use the options available and my presentation will also assess the available evidence and to try and provide some answers on when to utilise each treatment."
According to Professor Øresland, there are several studies [2,3,4] that have compared laparoscopic lavage to surgical resection for complicated diverticulitis. Overall, he said these studies demonstrate the importance of patient selection in the surgical decision-making process but, he cautioned, there is a lack long-term data.
In addition, he explained that there are limitations of both laparoscopic lavage and resection with a stoma. For patients who have undergone a laparoscopic lavage, sometimes a perforated cancer may mimic a perforated diverticulitis.
"For the laparoscopic lavage, you cannot be absolutely sure that this is not a cancer. So we still recommend an investigation of the colon at about six weeks after surgery. And when performing resection with a stoma, the problem is once you create a stoma, most patients will have it for the rest of their life. These patients have a lot of comorbidities, so one is hesitant to offer them elective stoma closure."
"I would encourage all surgeons, both young and experienced surgeons, who are involved in emergency care duties and who are seeing patients admitted with abdominal problems, to attend the session on diverticulitis," he concluded. "Diverticular disease has been with us for more than 50 years, but it is only in recent years we have developed new techniques, such as laparoscopic lavage, and we need to perform more research in order to learn more about how best to treat this disease."
- Everhart JE, Ruhl CE. Burden of digestive disease in the United States Part II: Lower Gastrointestinal Diseases. Gastroenterology. 2009;136:741–754
- Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial.
- Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA, Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW, Boermeester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA; Ladies trial colloborators.
- Lancet. 2015 Sep 26;386(10000):1269-77.
