Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe.
BACKGROUND
Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear.


OBJECTIVE
The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess.


METHODS
This was a retrospective chart review with prospective telephone follow-up of patients.


METHODS
The study was conducted at a large tertiary academic colorectal surgery practice in Canada.


METHODS
Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included.


METHODS
Long-term definitive nonoperative management of diverticular abscess.


METHODS
The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis.


RESULTS
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.


CONCLUSIONS
This study was limited by its retrospective design and modest sample size.


CONCLUSIONS
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.
1 Section of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada 2 Department of Radiology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada 3 Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
Richard
R
Garfinkle
Aaron
A
Kugler
Vincent
V
Pelsser
Carol-Ann
CA
Vasilevsky
Nancy
N
Morin
Philip
P
Gordon
Liane
L
Feldman
Marylise
M
Boutros
D018784:Abdominal Abscess / Q000209:etiology / Q000628:therapy*; D000359:Aftercare / Q000379:methods*; D000368:Aged; D003082:Colectomy; D004239:Diverticulitis, Colonic / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012189:Retrospective Studies; D012810:Sigmoid Diseases / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy; D016896:Treatment Outcome; D057832:Watchful Waiting