Vittoria Bellato interviews Johannes Schultz about ESCP’s Guidelines for the Management of Diverticular Disease ahead of ESCP's next Global Reach webinar 'Myths and Evidence in Diverticular Disease'.
Vittoria Bellato: I would firstly like to thank you and the guideline working groups for your great work which will easily guide many surgeons through evidence-based practice on diverticular disease.
Often doctors are reluctant to change clinical practice based on recent evidence. Is there any treatment or clinical recommendation on diverticular disease that you find hard to change in your daily practice, despite the evidence and your deep knowledge of the topic?
Johannes Schultz: First of all, thank you for inviting me to the webinar, I’m looking forward to presenting ESCP’s guidelines. To your question, yes we did have some trouble introducing the management of uncomplicated diverticulitis without antibiotics into daily routine even though there now is strong evidence that antibiotics do not improve outcomes for these patients. We started this process some years ago and published our first experience. By now I think very few of our patients with uncomplicated diverticulitis are receiving antibiotics, but the message needs constant repetition. It can be hard to change long-standing traditions.
VB: And are there any changes that you’ve made to your clinical practice after the publication of ESCP guidelines on diverticular disease?
JS: Actually, I must admit that the Scandinavian way of handling diverticular disease has been very much in line with the current guidelines. So in fact, I cannot think of one routine that we changed after the guideline was published.
VB: ESCP’s guidelines on diverticular disease [1] are really comprehensive and detailed. How long did the whole process take and how did you organise work among the working groups?
JS: We started off the project at ESCP's Annual Meeting in 2017 when Professor Willem Bemelman asked Professor Eva Angenete and myself to chair this project. We were already discussing themes for the different working groups.
To begin with, we were aiming to create a joint guideline with ASCRS and possibly EAES and SAGES. Unfortunately, EAES and SAGES were already advanced with work on their guideline and collaboration was not an option at that point. We had several online meetings with ASCRS’ guideline group but unfortunately this collaboration did not work out either, as we could not agree on a joint methodology.
The six working groups were formed by inviting colleagues based on their publication record in the field. We tried to involve colleagues from several ESCP member countries. The whole guideline panel agreed on the research questions for all six themes. Each group had 3-5 members and worked on a theme by making evidence tables and drafting supporting text and statements. We had two online voting rounds and a final face-to-face meeting to reach consensus.
VB: I noticed that the statement on CT classifications states that no particular classification is superior as a diagnostic tool. In your opinion would not the international and wide use of a classification based on radiological findings at the current time be desirable? (e.i. WJES ) [2] [Statement 2.4]
JS: An international agreement on a common CT classification would indeed be desirable especially when it comes to compare research results. However, that would need an agreement between several surgical societies. There have been many attempts to create new classifications, which in our opinion is just confusing the picture as class 2 can be class 3 in another classification. This is why we agreed not to create yet another classification. The modified Hinchey classification by Wasvary is probably the one that is most widely used. However, it does not account for the fundamental difference between patients with some pericolic air bubbles and those with distant free air and free fluid. In this respect the classification by WJES that you mentioned captures the whole picture a bit better, however, it is not widely used and does have some weaknesses. In my eyes it is most important that the CT describes the presence, location and size of: fluid collections, contained abscesses and extraluminal/free air collections.
VB: Can you describe in which selected case it is feasible to perform a laparoscopic lavage in purulent diverticulitis? [Statement 4.3]
JS: We have learned from the three randomised trials [3-5] that laparoscopic lavage is not as effective as resection to control the septic focus. However, the procedure has several advantages, particularly the lower stoma rate is very appealing. I would consider laparoscopic lavage for hemodynamically stable immunocompetent patients with purulent peritonitis who I think can tolerate a second hit of sepsis (i.e. not the frail or multimorbid).
VB: Would you try a conservative approach in an immunocompetent, hemodynamically stable, clinically not septic patient with radiological signs of extra luminal air and the isolate finding of a CRP> 500?
JS: The CT finding alone and the CRP level are not a good tool to guide the treatment. The clinical picture is very important. In absence of diffuse peritonitis and sepsis I would discuss the option of a conservative approach with the patient and would recommend antibiotics alone under close surveillance.
VB: Do you advocate the use of air leak test during laparoscopic lavage in order to guide surgical intervention (lavage only vs resection) in complicated diverticulitis with uncertain intra-operative findings?
JS: During reoperations of lavage patients in the randomised trials, an open communication between the bowel and the abdomen was frequently found. Therefore, I do think an air leak test is a good idea when performing laparoscopic lavage.
VB: The guidelines do not mention if there is any evidence on the common practice of on-table washout of the colon during different emergency surgery for acute complicated diverticulitis. Which is your view about the topic?
JS: That topic was in fact not discussed at all during the guideline project. There is no tradition for washouts in my hospital. During my career I have done a washout only once and remember it as time-consuming and troublesome. As there is no strong evidence for washouts being superior to no washout, I would not consider it.
VB: For which statement is it, in your opinion, most complicated to verify and build evidence due to difficulties on trial design and/or patient safety?
JS: There are several topics in diverticular disease that are difficult to investigate in clinical trials. There is elective surgery where you have patients with frequent recurrences and patients with ongoing symptoms. The two existing randomised trials have included both entities, which makes the interpretation of results difficult. Further, to correct for the considerable placebo effect of surgery one would have to perform a sham procedure in the conservative group, which is obviously problematic. In addition, emergency procedures are difficult to investigate as it may be difficult to get the patients consent in this situation. Finally, the need of colonoscopy after an episode of diverticulitis should be investigated in a randomised trial, however, that would need many patients and is therefore not feasible.
VB: What is the next most needed study on diverticular disease? And which trials are you most interested in awaiting the results of?
JS: As mentioned, there is a need of a randomised trial on the need of colonoscopy after complicated and uncomplicated diverticulitis. That was the most controversially debated topic during the guideline project. The results from several retrospective series are conflicting. From ongoing studies I’m awaiting the results of the DAMASCUS and the SCANDIV II study which both will cast a light on the current handling of complicated diverticulitis in different countries.
VB: What do you expect form the webinar debate on differences on diverticular disease epidemiology, diagnosis and treatment between East and West?
JS: The debate will be very interesting. There is quite a different incidence of diverticular disease between the East and West. Diverticular disease in the West is mostly located in the sigmoid colon, whereas there are many cases of right-sided diverticulitis in the East. Personally, I hope to learn more about the handling of right-sided diverticular disease which we do see sometimes also here in the West. Furthermore I’m keen to learn whether there are major differences in the handling of left-sided diverticular disease.
ESCP Global Reach Webinar, 18 June 2021: 'Myths and Evidence in Diverticular Disease’
References
- Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis. 2020 Sep;22 Suppl 2:5-28. doi: 10.1111/codi.15140. Epub 2020 Jul 7. PMID: 32638537.
- Sartelli M, Moore FA, Ansaloni L et al. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg 2015; 10: 3.
- Azhar N, Johanssen A, Sundström T, Folkesson J, Wallon C, Kørner H, Blecic L, Forsmo HM, Øresland T, Yaqub S, Buchwald P, Schultz JK; SCANDIV Study Group. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial. JAMA Surg. 2021 Feb 1;156(2):121-127. doi: 10.1001/jamasurg.2020.5618. PMID: 33355658; PMCID: PMC7758831.
- 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. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet. 2015 Sep 26;386(10000):1269-1277. doi: 10.1016/S0140-6736(15)61168-0. Epub 2015 Jul 22. Erratum in: Lancet. 2019 Jun 1;393(10187):2200. PMID: 26209030.
- Kohl A, Rosenberg J, Bock D, Bisgaard T, Skullman S, Thornell A, Gehrman J, Angenete E, Haglind E. Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis. Br J Surg. 2018 Aug;105(9):1128-1134. doi: 10.1002/bjs.10839. Epub 2018 Apr 16. PMID: 29663316; PMCID: PMC6055876.
