Colonic diverticular disease is common and increasing in prevalence in western populations because of population aging and the low fiber content of the average western diet. Clinical diverticulitis develops in 10 to 25 percent of people with diverticulae, but the role of surgical treatment in this common condition is controversial. Some studies indicate benefits following surgery in patients who experience chronic symptoms or repeated acute attacks of diverticulitis. Other studies conclude that prophylactic colonic resection cannot prevent recurrent disease and its complications. Thörn and colleagues studied all patients surgically treated for diverticular disease at a Swedish university hospital between 1989 and 1994 to assess the outcomes in clinical symptoms and patient satisfaction.
Of the 422 patients with diverticular disease (confirmed by colonoscopy or radiologic studies) who were referred to surgery, 72 underwent urgent surgery and 75 had elective procedures. The most common procedure, sigmoid resection, was performed on 84 percent of patients. The average age of the 24 men undergoing elective surgery was 56 years, and the average age of the 51 women was 62 years.
About 40 percent of patients had two or more verified acute attacks of diverticulitis, and this was the most common indication for surgery. One fourth of these patients had stenosis of the sigmoid colon. Preoperatively, 34 patients reported functional bowel symptoms, predominately constipation (50 percent), diarrhea (40 percent) or irritable bowel (10 percent). In addition, 28 patients had comorbidities that were predominately ischemic heart disease or lung conditions. No deaths were associated with surgery, but complications occurred in 25 patients (33 percent), and 10 patients (13 percent) required surgery for complications. Serious events included anastomotic leakage (four cases), bleeding (two cases), intra-abdominal abscess (two cases) and bowel obstruction (two cases). In addition, nine (12 percent) developed incisional hernia.
At follow-up, four patients had died from unrelated causes. Of the 71 remaining patients, 64 (90 percent) replied to the study questionnaire. The mean time since surgery was four years (range, 1.5 to 7.3 years). Fifty patients (78 percent) reported bowel function as excellent or good, 13 evaluated it as fair, and one patient reported worse bowel function following surgery. Patients with poorer outcomes had significantly more functional symptoms before surgery than patients with good outcomes. Recurrent diverticulitis occurred in six patients (8 percent), but none required additional surgical intervention.
The authors conclude that elective surgery in severe diverticular disease provides good outcomes and low rates of recurrence, but it is accompanied by postoperative complications. In addition, they stress the need to screen patients for functional bowel symptoms before surgery, because these patients may have less satisfactory results.