medwireNews: Elective laparoscopic sigmoid resection may be a viable option for patients with recurring, complicated, or persistent painful diverticulitis, preventing recurrences without increasing the risk for major complications, particularly in those with low quality of life (QoL), suggests a 4-year analysis of the LASER trial.
In an editorial related to the study published in JAMA Surgery, Sara Myers and Jennifer Davids (both at Boston Medical Center, Massachusetts, USA) write: “Identifying who will benefit from upfront elective surgery for diverticular disease is critically important work.”
They say: “These findings provide a valuable framework to guide conversations between clinicians and patients who are struggling to decide between surgery and conservative measures based on uncertain longer-term outcomes.”
In the open-label trial, the investigators randomly assigned 90 Finnish patients with diverticulitis to receive elective sigmoid resection or conservative management, comprising educational materials on constipation and diverticulitis that recommended increased dietary fiber intake, and a prescription for a fiber supplement.
Eligible participants had experienced three or more episodes of left colon diverticulitis within a 2-year period with at least one verified using computed tomography (CT); one or more episodes of complicated left colonic diverticulitis treated conservatively; or prolonged pain or disturbance in bowel habits over 3 months after an episode of CT-verified acute left colonic diverticulitis.
Women made up 69% of the patient cohort and were a mean of 57.1 years old, while men (31%) were aged a mean of 54.1 years.
Among those with QoL questionnaire responses available, the researchers found that the mean BMI was similar, at 29.5 kg/m² and 28.7 kg/m² in the surgery (n=38) and conservative treatment groups (n=40), respectively. Hypertension was the most prevalent comorbidity, affecting 40% of patients in the surgery group and 28% in the conservative group, and the most common inclusion criteria included recurrent diverticulitis (82 and 73%, respectively) and complicated diverticulitis (26 and 28%).
At 4 years of follow-up, patients in the surgery group had a numerically higher Gastrointestinal Quality of Life Index (GIQLI) score than the conservative treatment group, at a mean of 115.31 versus 109.78 points out of a possible 144 points, where higher scores indicate a better QoL. However, the difference was not statistically significant. There was also no significant difference between the groups in terms of the overall health measure, the 36-Item Short Form Health Survey (SF-36).
Ville Sallinen (University of Helsinki, Finland) and colleagues point out that, in accordance with the study protocol, 27% of patients in the conservative treatment group underwent surgery after a minimum of 6 months at the discretion of the patient or surgeon and primarily due to recurring diverticulitis or pain, while 5% underwent emergency surgery for pericolic abscess.
Post-hoc analyses showed that these crossover patients had significantly lower mean GIQLI scores at baseline than the 30 patients who only received conservative treatment (90.79 vs 104.58 points). After surgery, the patients’ scores improved significantly by an average of 17.57 points, from 91.25 points just before surgery to 108.82 points afterwards.
For the surgery group as a whole (including crossover patients), recurrent diverticulitis occurred in significantly fewer patients compared with the conservative treatment group, at rates of 16% versus 92%. The researchers note that the rate was lower still, at 10%, when only those who were assigned to undergo surgery (excluding crossover patients) were assessed.
Sallinen et al observed that minor postoperative complications, such as superficial wound infection and intraluminal bleeding, were more common among patients in the surgery group than the conservative treatment group, at respective rates of 27% and 5%.
However, both groups had similar rates of major postoperative complications (Clavien–Dindo grade III or higher), at 10% in the surgery arm and 11% in the conservative treatment arm, which the team says is “reassuring in a sense that early upfront surgery did not increase [the] risk.” These included reoperations for anastomotic leakage (5 vs 7%), adhesions (0 vs 2%), and incisional hernias (2 vs 5%).
The investigators also note that the halving of the incisional hernia rate among patients undergoing surgery versus conservative treatment was also seen for stomas, which were needed by two versus four patients, respectively. Additionally, the rate of major complications was 10% among patients who received upfront surgery, compared with 36% in the 14 patients who switched to surgery from conservative treatment, “favoring early surgery,” they say.
The team adds: “[T[his indicates that patients who postpone surgery would likely have a higher risk of major postoperative complications should they need surgery later.”
Myers and Davids caution, however, that the two groups “were small and heterogeneous,” adding that “without stratification by type of diverticular disease, the ability to extrapolate results to predict risk of emergency surgery or complications is limited.”
They conclude that “incorporating an analysis of the reasoning for crossover in the study design as well as a qualitative component to elucidate surgeon and patient perspectives on this decision would have improved our understanding of this important aspect of the study.”
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