Mistakes in ... Booklet 2020 - 10

ueg education

patients require a different (more aggressive)
therapy than elderly patients. We have performed
a systematic review (unpublished results) to
answer this question; a total of 27 studies were
included, half of them only included cases of
left-sided diverticulitis and 20 of 27 studies were
conducted in Europe. The data from 20 studies
that reported the stage of diverticulitis at
presentation were pooled, resulting in analysis
of 7,477 patients. There was substantial
heterogeneity among the studies and the level of
evidence was low. The results showed that young
age was not associated with an increased risk
of complicated diverticulitis or the need for
emergency surgery or percutaneous drainage.
Twelve studies mentioned the recurrence rate,
whereas 3 of 12 studies took into account the
length of follow-up, making them more reliable
in terms of drawing any conclusions. Young age
was also not associated with an increased risk of
recurrence of diverticulitis.
Although the evidence is not that strong, there
is no evidence that young patients should be
treated any differently to elderly patients-young
patients do not suffer from a more severe
disease course or have a higher risk of recurrent
diverticulitis. However, it is important to keep
in mind that younger patients have different
demands because many of them work or
participate in sporting activities. The decision on
whether or not to perform elective surgery for
recurrent disease or chronic complaints is
influenced by such individual factors, so lower
thresholds for surgery in younger patients may
lead to a higher proportion undergoing elective
surgery.

Mistake 9 Assuming routine colonoscopy
is always indicated after a first episode of
acute diverticulitis
In the past, routine colonoscopy was traditionally
recommended after a first episode of acute
diverticulitis to rule out coexisting malignancy,
but at that time acute diverticulitis was often a
clinical diagnosis. Since CT imaging has
improved greatly over the years and is used
more regularly to diagnose diverticulitis, the
question of whether routine colonoscopy
after an episode of acute diverticulitis is still
necessary has come up for debate.12,13 However,
most guidelines have not been updated and still
recommend routine colonoscopy after acute
diverticulitis, and many clinicians still follow
these guidelines.23-28
A 2019 systematic review and meta-analysis
has altered recommendations concerning the
follow-up after acute diverticulitis.29 An important
conclusion of the meta-analysis was that acute
diverticulitis does not increase the future risk of
colorectal carcinoma. Moreover, this systematic
review also shows that the risk of colorectal
carcinoma being present at the initial
34

Mistakes in... 2019

presentation is comparable among patients
with CT-diagnosed acute diverticulitis versus
asymptomatic controls. Older studies that
included patients who had a clinical rather than
CT diagnosis of acute diverticulititis have found
an association with colorectal carcinoma within
the first year of presentation. This association is
probably due to misdiagnosis, because the
development of carcinoma from a dysplastic or
premalignant lesion takes longer than 1 year.
In general, the potential gain of performing
colonoscopy, such as detection of an unsuspected
malignancy, should be weighed against its
potential disadvantages, such as the risk of
perforation, patient discomfort and the burden
of healthcare utilisation. Routine colonoscopy
may be omitted in patients with an episode of
CT-verified uncomplicated diverticulitis, and they
can be referred back to the colorectal cancer
screening program. However, routine colonoscopy
should remain the protocol for patients with
complicated diverticulitis treated without
resection and those with ongoing complaints
(pain and/or fever and/or changed stools) after
CT-verified uncomplicated diverticulitis. Such a
colonoscopy should be performed at least 6 weeks
after acute disease.

Mistake 10 Performing a Hartmann's
procedure instead of a primary anastomosis
for perforated diverticulitis
When a patient is diagnosed with perforated
diverticulitis and has a purulent (Hinchey III) or
faecal (Hinchey IV) peritonitis, emergency surgery
is indicated. Many surgeons still believe that a
Hartmann's procedure-surgical resection of
the affected part of the colon followed by
construction of an end colostomy (Figure 4a)-is
the best treatment. However, three randomized
controlled trials (RCTs) have compared sigmoid
resection with a primary anastomosis (Figure 4b)
with a Hartmann's procedure.30-32 Morbidity and
mortality are comparable for sigmoid resection
with primary anastomosis and sigmoid resection

a

with end colostomy. Primary anastomosis results
in a lower stoma rate at long-term follow-up. When
choosing a stoma in case of a primary anastomosis
a diverting loop ileostomy is usually performed,
which is less difficult to reverse. Thereby, for
sigmoid resection and primary anastomosis, the
number of permanent stomas is lower compared
with a Hartmann's procedure. Of critical note,
however, is that all three clinical trials were
prematurely terminated and their study designs
were not optimal.
Another RCT published in 2019 compared both
surgical interventions for perforated diverticulitis
(the LADIES trial), and provides strong evidence
that primary resection with anastomosis is a
more appropriate treatment than a Hartmann's
procedure for patients with acute diverticulitis with
purulent or faecal peritonitis.33 This preference is
related to a better 12-month stoma-free survival and
a reduced risk of morbidity related to stoma reversal,
which adds up to comparable short-term morbidity
and mortality but with a lower proportion of
stomas being present. This recommendation
applies to patients who are haemodynamically
stable and immunocompetent.
Finally, a large national retrospective cohort
study comprising 67,721 patients who underwent
concurrent faecal diversion generated different
results.34 Indeed, in this study patients who
underwent end colostomy (65,084 of 67,721
patients, 96.1%), had a lower risk for
complications compared with patients who
underwent anastomosis and ileostomy (2,637
of 67,721 patients, 3.9%); 23.3 % versus 32.1%
(P = < 0.001). The in-hospital mortality rate
was higher in the group undergoing primary
anastomosis and diversion; 16.0% versus 6.4%
(P = 0.001). However, due to the retrospective
nature of this study selection bias is a serious
limitation, as a mere 3.9% of patients received
a primary anastomosis. Moreover, we have
no knowledge about the experience and
subspecialty of the surgeons performing the
operations in these 67,721 patients. At present,
we should, therefore, rely on the data from the

b

Figure 4 | Surgical treatment of diverticulitis. a | Hartmann's procedure, a surgical resection of the affected
part of the colon and construction of an end colostomy. b | Sigmoid resection and primary anastomosis.



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