Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe.

Abstract

Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear. The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess. This was a retrospective chart review with prospective telephone follow-up of patients. The study was conducted at a large tertiary academic colorectal surgery practice in Canada. Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included. Long-term definitive nonoperative management of diverticular abscess. The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis. Of 135 patients with acute diverticulitis complicated by abscess, a total of 73 patients were managed with nonoperative intent and long-term expectant management. The median follow-up was 62 (Q1 to Q3: 28-98) months. After resolution of the index episode, 22 patients [30.1% (95% CI, 19.6%-40.6%)] experienced a recurrent episode of diverticulitis at a median of 23 (range, 9-40) months. Two patients [2.7% (95% CI, -1.0% to 6.4%)] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months. Both patients underwent reversal after 4 and 8 months. Seven [9.6% (95% CI, 2.8%-16.4%)] patients experienced a complicated recurrence and underwent an elective sigmoidectomy [median time to colectomy, 33 (range, 16-56) months]. Thirteen patients [17.8% (95% CI, 9.0%-26.6%)] experienced an uncomplicated recurrence, all of whom were managed with continued nonoperative intent [median follow-up, 81 (range, 34-115) months]. No mortality occurred. On multivariate logistic regression, female gender (p = 0.048) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess (p = 0.020) were associated with a recurrent episode. This study was limited by its retrospective design and modest sample size. After initial successful nonoperative management of diverticulitis with abscess, expectant management with nonoperative intent is a safe long-term option with low rates of surgery, especially in the emergency setting. See Video, Supplemental Digital Content 1, on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234.