Indications for Elective Sigmoid Resection in Diverticular Disease

Introduction: To prevent an acute surgery, classic indications for elective sigmoid resections concerning diverticulitis have usually been based on the number of recurrent episodes. Since 2005 these indications have been challenged, primarily because the majority of patients first present themselves with acute complications at their first episode. Methods: Between 1990 and 2000, a cohort analysis was conducted involving all patients admitted to the VU University Medical Center with the diagnosis of diverticulitis, with a follow-up until January 2009. To identify those patients who might benefit from elective sigmoid resection, several risk factors were analyzed. Results: Of 291 patients examined, 111 (38%) were treated conservatively and 180 (62%) underwent surgery, of which 108 acute and 72 elective. The conservatively treated episodes of diverticulitis showed a recurrence rate of 48% (88 patients). Indications for elective surgery were recurrent attacks of diverticulitis with persistent complaints (36%), complaints of stenosis (40%), fistula (14%), persistent abscesses (3%), and recurrent diverticular bleeding (7%). Of the 74% of the patients approached laparoscopically, the overall morbidity was 22% with no mortality. The main indication for an AO was perforation with general peritonitis, holding for 57% of the acutely operated patients. Other indications were abscesses (22%), stenosis with obstruction (11%), failure of conservative therapy (6%), or diverticular bleeding (4%). Hartmann's procedure was the most frequently performed procedure (58%). This acutely operated population was associated with high morbidity (56%) and mortality (13%), perforation leads to 10% mortality and other causes to 3%. Of those patients undergoing acute surgery, 20% had a history of diverticulitis. Moreover, risk factor analysis showed that those patients having one or more of the following indications: (1) using immunosuppression therapy, (2) having chronic renal failure, or (3) collagen-vascular diseases, had a significant 5-fold greater risk (36% vs. 7%) of a perforation in recurrent episodes of diverticulitis. Conclusion: In the treatment of diverticular disease, indications for an elective sigmoid resection should not be based on the number of episodes only. Clear indications for elective sigmoid resections are complaints of stenosis, fistulas, or recurrent diverticular bleeding. Furthermore, an elective sigmoid resection might be justified in high-risk patients, after a conservatively treated episode of diverticulitis, who use immunosuppression therapy and have chronic renal failure or collagen-vascular diseases.