Fleshman, J. (2016). “Improving Treatment of Uncomplicated Diverticulitis: The Old Appendicitis.” JAMA Surg. Feb 10. [Epub ahead of print]
Full text of this article.
We continue to struggle with the perfect definition of the indication for an elective operation in the patient with diverticulitis. Simianu et al,1 in their review of the MarketScan Commercial Claims and Encounters Database, have attempted to determine the influences that drive early and late operation on patients with diverticulitis. The group from University of Washington, Swedish Hospital of Seattle, and Virginia Mason Clinic hypothesized that patients commonly undergo early (<3 episodes) elective resection for diverticulitis, especially when the patient is young and responsible for the cost of the operation, which is done laparoscopically, and the preceding episodes have been frequent over a short period. Simianu et al concluded that none of these factors influenced the decision to operate and at least 50% of patients had early operations. The database is a commercial insurance administrative database with all of the limitations of an administrative database. Since these are insured, non–immune-compromised patients with uncomplicated disease, there is an element of selection and bias. The clinical data that normally influence the timing of an operation are not available (computed tomography, white blood cell count, vital signs). In an interesting twist, the definition of an incident of diverticulitis included the use of antibiotics as an outpatient or an inpatient in combination with the code for diverticulitis or the prescription of ciprofloxacin and metronidazole, in combination, in a patient with a previous episode of diverticulitis. This should have increased the number of episodes beyond the 2 cases that have historically been used as an indication for an operation. It did not. There are, therefore, surgeons who persist in operating immediately for more than 1 episode of diverticulitis. This is reminiscent of the way we treated diverticulitis in past years. Why have we not seen an improvement in the consistency of patterns of elective operation? Can we have surgeons who hold fiercely onto autonomy? Why have surgeons in the southern part of the United States continued to operate early on patients with uncomplicated diverticulitis when the patients are not noticeably different from the patients elsewhere? If capitated patients are the least likely to have early operation of the insured patients from the multiple insurance plans represented in this database, it would seem that protocols and peer review are working to reduce unnecessary operations in these patients. There was also an association between open operations and early operation. Could this indicate that resistance to change is contributing to the problem? Older surgeons who have not adopted laparoscopic techniques may also be holding on to the outdated thoughts toward diverticulitis. Assuming that not all patients who underwent operation for early diverticulitis would have eventually have required operation, there is a possibility that we, as surgeons concerned with population health, could reduce the cost of care for these patients by prescribing bulk fiber and encouraging a healthy diet high in vegetables, all of which may help to avoid another episode of diverticulitis. There should never be a financial reason for operating on an early case of diverticulitis. Chronic malignant smoldering diverticulitis, that has caused stricturing and resulted in a difficult operation to remove the disease, usually develops after many more than 3 episodes of diverticulitis. It is my opinion that this should not be considered an excuse for early operation on uncomplicated diverticulitis. Patients usually have symptoms that point to the development of severe disease, such as chronic rather than intermittent pain, incomplete resolution of fever and leukocytosis, and partial obstructive symptoms with each episode. As Simianu et al mentioned in their article,1 time between episodes may be a significant influence on this progression as well. The concerned, informed, and ethical surgeon will adhere to the recommendations proposed by almost all of the national surgical societies to improve the care for patients with diverticulitis and avoid operation on early uncomplicated diverticulitis. This review did not indicate whether there is a difference between academic, major metropolitan community, and small community hospitals in their treatment of diverticulitis. The mobility of patients in search of health care should allow the appropriate care of uncomplicated diverticulitis as the public is better educated in the modern method of treating diverticulitis. As with all interesting studies, there are always more questions than answers at the end of the study. The authors acknowledge that the next step should be a focused prospective approach to answering the number of questions raised from their article. (Excerpt from text.)