Rethinking elective colectomy for diverticulitis in Washington State

Abstract

The management of diverticulitis is becoming an increasingly important problem, with an estimated 1.5 million inpatient days and 300,000 admissions each year.1-3 While 10-20% of people admitted to the hospital for diverticulitis undergo emergency resection, 4,5 regardless of whether or not patients undergo surgery during initial presentation, they remain at lifetime risk for recurrent episodes and hospitalizations. Surgeons play an integral role in counseling patients on the risks of recurrence versus the risks of an operation, adhering to the premise that elective, "prophylactic" colectomy can prevent future episodes of diverticulitis and emergency colostomy.6,7 Accordingly, diverticulitis is one of the leading indications for elective colon resection.8,9 Over the last decade, however, the relationship between elective and emergency surgery has come into question. With most emergency resections being performed in patients without a prior hospitalization,4,5,10 it has become apparent that diverticulitis recurrences are a poor predictor of need for future emergency operation at the population level. Furthermore, the observed increase in the rates of elective colectomy has not correlated with decreases in emergency colectomy.11 In light of these gaps in evidence, a number of international professional societies have indicated that surgery should no longer be performed based on the number of prior episodes of diverticulitis. 1,6,12,13 This thesis encapsulates three studies that address the evidence gaps about elective colectomy for diverticulitis by assessing patterns of elective colectomy at the population level in Washington State. The first study describes the relationship between the incidence in elective and emergency colectomy over the last two and half decades.14 The second study considers surgeon-reported indications for elective colectomy across the majority of hospitals in Washington.15 The third study explores the impact of diverticulitis episode number on successful completion of laparoscopic surgery, the dominant operative approach used for diverticulitis in the modern era. 16 Together, these studies provide contemporary epidemiologic evidence for patterns in treatment of diverticulitis at a population-level, and motivate future work to guide decision-making related to elective surgery for this disease.