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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Saturday, February 01, 2014
February, 2014 Journal Club
Moderator: Dr. Susan Galandiuk
 
Article: Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis: A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial).
Biondo, Sebastiano; Golda, Thomas; Kreisler, Esther; Espin, Eloy; Vallribera, Francesc; Oteiza, Fabiola; Codina-Cazador, Antonio; Pujadas, Marcel; Flor, Blas
Annals of Surgery. 259(1):38-44, January 2014.
 
Summary: The authors present a multi-center, randomized controlled trial conducted in Spain between 2009 and 2011 designed to compare outpatient versus inpatient antibiotic treatment of uncomplicated diverticulitis. There were 66 patients in each study arm. Importantly, the 132 randomized patients represent only 29 % of the 453 patients with diverticulitis seen during the study period. The exclusion criteria are extensive and 27 % of eligible patients refused to participate. Patients seem to have been selected largely on CT findings, for evidence of diverticulitis without evidence of pericolic abscess (modified Hinchey classification Ia). All patients received a dose of intravenous (IV) antibiotics in the Emergency Room and were then randomized to hospital admission and IV antibiotics or to hospital discharge and oral antibiotics. Patients were followed out to 60 days, with the primary end point being the failure of outpatient treatment and the need for hospital readmission which was similar between the groups. Quality of life and cost were also evaluated. There was no difference between groups with respect to treatment failure or quality of life; however costs were expectedly lower in the outpatient group. It is important to note, that in this study in contrast to some others 1) follow-up is very short, 2) we are not provided with important clinical data often provided in many studies to assess severity of diverticulitis such as temperature at the time of initial evaluation, degree of abdominal pain, C-reactive protein. The mean leukocyte level of 11.1 seems very modest.
 

Questions:

1.       Are patients with such mild diverticulitis even seen by surgeons at your institution? Would such patients seen at your institution agree to outpatient treatment of abdominal pain only with acetaminophen as was done in this study?

 

2.       How do you explain the results of the much larger trial (reference 30 as quoted) showing that there was no difference in outcome (complications or recurrent diverticulitis) between patients with uncomplicated diverticulitis who were treated in hospital with, as compared to without antibiotics and then followed for a full 1 year?

 

3.       In one study (Buchs et al, Br J Surg 2013;100:976-979), in which 280 patients with uncomplicated diverticulitis were followed for a median 24 months, only 16 % experienced a second episode of diverticulitis. Given this, are we greatly over-treating these patients?

 

4.       Finally, do you question patients with diverticulitis regarding bowel habits? Do you assess women with diverticulitis for the presence of a rectocele, the most common cause of constipation in women?

 

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

About the Author

Dr. Mary T. Hawn
Dr. Mary T. Hawn is Professor of Surgery, Chief of the Division of Gastrointestinal Surgery and Vice Chair for Quality and Clinical Effectiveness at the University of Alabama at Birmingham. Her research interests are in the area of safety and effectiveness of surgical procedures and their policy implications.

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