CHICAGO (FRONTLINE MEDICAL NEWS) Observation, compared with elective resection, was associated with significantly increased recurrence rates in a single-center randomized, controlled trial of patients who had successfully recovered via nonoperative management from their first episode of acute sigmoid diverticulitis with extraluminal air/abscess.

Recurrence rates in 111 patients randomized to observation or elective resection were 31% in the observation group and 7% in the resection group, at 15 and 18 months, respectively, Dr. Ryan Bendl of State University of New York, Stony Brook reported at the annual meeting of the American Surgical Association.

Patients in the two groups were comparable with respect to age, sex, body mass index, Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM), and comorbidities, he noted.

Subjects included in the single-center study were adults admitted for a first episode of acute diverticulitis with abscess or extraluminal air who were managed nonoperatively with intravenous antibiotics, a period of nothing by mouth, drainage, and total parenteral nutrition followed by colonoscopy. They were randomized 3:1 to observation or resection, and 68% of the elective resection patients underwent minimally invasive surgery. The study’s primary endpoint was recurrent diverticulitis defined as an acute episode confirmed by computed tomography and requiring hospitalization with intravenous antibiotics.

Diverticulitis accounted for more than 300,000 hospital admissions in 2010 in the United States alone, and 10%-20% of patients had abscess formation. At one time, most patients were managed with immediate operative intervention, but medical and radiologic advances have led to a shift toward nonoperative management, Dr. Bendl said.

Some prior studies have suggested that recurrence rates are higher with nonoperative management, and the current study supports those data.

However, despite the significant increase in the recurrence rate with observation vs. resection, most patients in the observation group did not experience recurrence, and of those who did, none had peritonitis.

“All those with recurrences were successfully treated again using nonoperative management,” he said.

This study was supported in part by grants from Merck and Covidien. Dr. Bendl reported having no relevant financial disclosures.


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