Recent Trials in the management of Diverticulitis

2. Adeel Abbas Dhahri

3.  Diverticulum?
 Diverticulosis?
 Diverticular Disease?
 Diverticulitis?

4.  After 50 years of age
 Colonic diverticulosis is the most commonly reported
finding reported on colonoscopy usually performed for
colon cancer screening

5. Factors
 Smoking
 Physical activity
 Dietary habits and especially fibre consumption

6. Edward John Hinchey: Father of Modern Age of Acute
Complicated Diverticulitis of the Colon

7.  Hinchey Classification*
 Modified Hinchey Classification**
 *Hinchey, E.J., Schaal, P.G. and Richard, G.K. Treatment of perforated diverticular disease of the colon. Advances in Surgery 12:85-
109, 1978
 ** Sher ME, Agachan F, Bortul M, et al. Laparoscopic surgery for diverticulitis. Surg Endosc. 1997;11:264–267.

8. Hinchey classification Modified Hinchey classification by Sher et al.
I
Pericolic abscess or
phlegmon
I Pericolic abscess
II
Pelvic,
intraabdominal, or
retroperitoneal
abscess
IIa
Distant abscess
amendable to
percutaneous
drainage
IIb
Complex abscess
associated with
fistula
III
Generalized purulent
peritonitis
III
Generalized purulent
peritonitis
IV
Generalized faecal
peritonitis
IV Faecal peritonitis

9. Diagnosis
 CT
 USS

10.  CRP
 A useful biomarker of inflammation
 A predictor of the clinical severity
 A cut-off value of 170 mg/L significantly discriminated
severe from mild diverticulitis (P < 0.00001).
 Kechagias A, Rautio T, Kechagias G, Mäkelä J. The role of C-reactive protein in the prediction of the
clinical severity of acute diverticulitis. Am Surg. 2014;80:391–5

11. Guidelines
 NICE
 RCS Commissioning Guide
 WSES
 US
 European

12. Trials
 AVOD study - Antibiotika Vid Okomplicerad
Divertikulit
 DIVER trial - Hospitalization or Ambulatory
Treatment of Acute Uncomplicated Diverticulitis
 LADIES trial - Laparoscopic peritoneal lavage or
resection for purulent peritonitis and Hartmann's
procedure or resection with primary anastomosis for
purulent or faecal peritonitis in perforated
diverticulitis

13.  Majority of Acute Diverticulitis ?
 Uncomplicated?
 Complicated?
 Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular
disease. Arch Surg. 2005;140:681–5
 Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute
diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140:576–81
 15% present as complications.

14.  Generally the first episode is the most severe.
 1st Recurrence 13.3% of patients
 2nd Recurrence 3.9%.
 Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular
disease. Arch Surg. 2005;140:681–5
 Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute
diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140:576–81

15.  80.6% of patients non-operative treatment
 Emergency colectomy was performed in 19.4%.
 Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does
not mandate routine elective colectomy. Arch Surg. 2005;140:576–81

16.  Antibiotics are mandatory in the treatment of Acute
Diverticulitis?

17.  Newer hypotheses
 “Acute Diverticulitis may be an inflammatory
rather than an infectious condition”
 Rezapour M, Ali S, Stollman N. Diverticular disease: an update on pathogenesis and management. Gut Liver. 2017
May 12

18.  “An observational approach to acute uncomplicated
diverticulitis is not inferior to antibiotic treatment and
does not result in increased complication or recurrence
rates.”
 “No differences about the median time to recovery were
found.”
 AVOD Trial
 Daniels L, et al. Dutch DD(3D) Collaborative Study Group. Randomized clinical trial of observational versus
antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg.
2017;104:52–61
 Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst
Rev. 2012;11:CD009092

19. DIVER Trial
 Hospitalization or Ambulatory Treatment of Acute
Diverticulitis
 Outpatient treatment is safe and effective in selected
patients with uncomplicated acute diverticulitis

21. Ambulatory treatment of
uncomplicated Acute
Diverticulitis is safe,
effective and economically
efficient.

22. LADIES Trial
 LOLA – arm
 DIVA - arm

23.  Recruitment terminated early after interim analysis of
results demonstrated poorer outcomes in the
laparoscopy group: At 30 days, the combined primary
outcome was 39% in the laparoscopic lavage group
compared with 19% in the sigmoid colectomy group

24.  Results;
 Do Not Favour A Lavage Strategy

25. ACPGBI Position Statement on Elective Resection
for Diverticulitis
 The Association of Coloproctologists of Great Britain
and Ireland clearly reject the need for universal
elective resection
 “The decision regarding whether to offer resection
should be made on an individual basis and the surgeon
should involve the radiologists and pathologists in this
decision, in addition to the patients themselves...”

26. High Fibre or Low Fibre Diet?

27. Dietary Fibres
 European guidelines support the use of a high-
fibre diet for the prevention of acute diverticulitis
 Sánchez-Velázquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. Eur
J Gastroenterol Hepatol. 2016;28:622–7
 Kruis W, Germer CT, Leifeld L German Society for Gastroenterology, Digestive and Metabolic Diseases and The
German Society for General and Visceral Surgery. Diverticular disease: guidelines of the German society for
gastroenterology, digestive and metabolic diseases and the German society for general and visceral surgery. Digestion.
2014;90:190–207
 Pietrzak A, Bartnik W, Szczepkowski M, Krokowicz P, Dziki A, Reguła J, Wallner G. Polish interdisciplinary consensus
on diagnostics and treatment of colonic diverticulosis. Pol Przegl Chir. 2015;87:203–20
 Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi
G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and
diverticular disease. United European Gastroenterol J. 2014;2:413–42

28. Rifaximin
 Rifaximin may reduce the risk of
 occurrence when associated with fibre intake
 recurrence of diverticulitis

29. Mesalazine
 No clear evidence that mesalazine reduces episodes
 Most European guidelines do not recommend

30. Probiotics
 Italian guidelines do not support