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Clinical Practice Guidelines for the Treatment of Left-Sided Colonic

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Clinical Practice Guidelines for the Treatment of Left-Sided Colonic CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of 05/30/2020 on C33fy907TbIFyHx640yafcu/EMfLBj0ena7lfLfVXefdPtD2mEHxq/BpP2kvObheZQ/k1t9qDSwPpsO8GTaUdiwuQjK1pQWMb33hySnFF8XYif3Wu1+aLfG/RwOoqepMVfjbRG/tpOg= by https://journals.lww.com/dcrjournal from Downloaded Left-Sided Colonic Diverticulitis Downloaded Jason Hall, M.D., M.P.H.1 • Karin Hardiman, M.D., Ph.D.2 • Sang Lee, M.D.3 from 4 5 6 https://journals.lww.com/dcrjournal Amy Lightner, M.D. • Luca Stocchi, M.D. • Ian M. Paquette, M.D. Scott R. Steele, M.D., M.B.A.4 • Daniel L. Feingold, M.D.7 • Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons by 1 Section of Colon and Rectal Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts C33fy907TbIFyHx640yafcu/EMfLBj0ena7lfLfVXefdPtD2mEHxq/BpP2kvObheZQ/k1t9qDSwPpsO8GTaUdiwuQjK1pQWMb33hySnFF8XYif3Wu1+aLfG/RwOoqepMVfjbRG/tpOg= 2 Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, Alabama 3 Division of Colon and Rectal Surgery, USC Keck School of Medicine, Los Angeles, California 4 Department of Colorectal Surgery, Cleveland Clinic Cleveland, Cleveland, Ohio 5 Division of Colorectal Surgery, Mayo Clinic Florida, Jacksonville, Florida 6 Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio 7 Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey he American Society of Colon and Rectal Surgeons care workers, and patients who desire information about (ASCRS) is dedicated to ensuring high-quality pa- the management of the conditions addressed by the topics Ttient care by advancing the science, prevention, covered in these guidelines.These guidelines should not be and management of disorders and diseases of the colon, deemed inclusive of all proper methods of care or exclu- rectum, and anus. The Clinical Practice Guidelines Com- sive of methods of care reasonably directed toward obtain- mittee is composed of society members who are chosen ing the same results. The ultimate judgment regarding the because they have demonstrated expertise in the specialty propriety of any specific procedure must be made by the of colon and rectal surgery. This committee was created physician in light of all the circumstances presented by the to lead international efforts in defining quality care for individual patient. conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best a- vailable evidence. While not proscriptive, these guidelines METHODOLOGY provide information on which decisions can be made and These guidelines are constructed on the platform of do not dictate a specific form of treatment. These guide- the previously published Practice Parameters for the lines are intended for the use of all practitioners, health Treatment of Sigmoid Diverticulitis published by the American Society of Colon and Rectal Surgeons (AS- 1 Earn Continuing Education (CME) credit online at cme.lww.com. CRS) in 2014. A systematic search was conducted un- der the guidance of an information services librarian. Supplemental digital content is available for this article. Direct URL ci- This search strategy is outlined under the search ap- on tations appear in the printed text, and links to the digital files are pro- pendices (see Supplemental Digital Content, http:// 05/30/2020 vided in the HTML and PDF versions of this article on the journal’s Web links.lww.com/DCR/B209). The PubMed, EMBASE, site (www.dcrjournal.com). Cochrane, and Web of Science databases were searched Funding/Support: None reported. from January 1, 2013, until October 26, 2019. Relevant manuscripts identified by individual authors were also Financial Disclosures: None reported. included. Key word combinations using the MeSH terms including “Diverticulitis,” “Diverticulosis,” “Diverticu- Correspondence: Daniel L. Feingold, M.D., Professor and Chair, lar,” “Colonic,” “Colon Diverticulosis,” “Surgery,” “Med- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ. ical Therapy,” “Antibiotics,” “Probiotics,” “Laparoscopic Dis Colon Rectum 2020; 63: 728–747 Lavage,” “Mesalamine,” “Rifaximin,” and “Surgery” were DOI: 10.1097/DCR.0000000000001679 performed. The search was limited to English language © The ASCRS 2020 abstracts with human subjects. A directed search of ref- 728 DISEASES OF THE COLON & RECTUM VOLUME 63: 6 (2020) DISEASES OF THE COLON & RECTUM VOLUME 63: 6 (2020) 729 erences embedded in the candidate publications was the studies reviewed in this guideline used and defined also performed. Emphasis was placed on prospective recurrence differently. trials, meta-analyses, systematic reviews, and practice guidelines. Peer-reviewed observational studies and ret- rospective studies were included when higher-quality STATEMENT OF THE PROBLEM evidence was insufficient. In brief, a total of 4885 unique The prevalence of diverticular disease has risen steadily in journal titles were identified. Initial review of the search industrialized nations over the past few decades.5,6 A 2016 results led to the exclusion of 4223 titles based on irrel- study using data from the National Inpatient Sample esti- evance of the title or because they consisted of a case mated that the prevalence of hospitalization for divertic- report, letter to the editor, or nonsystematic review. A ulitis increased from 74.1 of 100,000 in 2000 to a peak of review of the remaining 662 titles included assessment 96.0 of 100,000 in 2008.7 These authors found that there of the full-length articles. This led to exclusion of an were 2,151,023 hospitalizations for diverticulitis during additional 494 titles for which similar but higher-level this time period with an average of 195,548 admissions evidence was available. The remaining 168 titles were per year.7 Another study compiled data from the National considered for grading of the recommendations (Fig. 1). Ambulatory Medical Care Survey and the National Hos- The final source material used was evaluated for the pital Ambulatory Medical Care Survey and found that in methodological quality, the evidence base was exam- 2010 there were more than 2.7 million discharges in the ined, and a treatment guideline was formulated by the ambulatory setting associated with a diagnosis of diver- subcommittee for this guideline. The final grade of rec- ticular disease, and that in 2012 there were more than ommendation and level of evidence for each statement 340,000 emergency department visits associated with a di- were determined using the Grades of Recommendation, agnosis of diverticulitis and 215,560 of these patients were Assessment, Development, and Evaluation system (Ta- admitted. Admission was associated with a median length ble 1).2 When agreement was incomplete regarding the of stay of 4 days and a median cost of treatment of US evidence base or treatment guideline, consensus from $6333.8 The authors recently used updated data from the the committee chair, vice chair, and 2 assigned review- same 2 surveys and estimated that in 2014 there were 1.92 ers determined the outcome. Members of the ASCRS million patients diagnosed with diverticular disease in the Clinical Practice Guidelines Committee worked in joint ambulatory setting.9 production of these guidelines from inception to pub- Another contemporary analysis demonstrated that lication. Recommendations formulated by the subcom- the rate of diverticulitis-related emergency department mittee were reviewed by the entire Clinical Practice visits rose 26.8% from 89.8 to 113.9 visits per 100,000 Guidelines Committee. The submission was peer-re- population between 2006 and 2013 and that the aggregate viewed by Diseases of the Colon & Rectum and the final national cost of these visits was $1.6 billion in 2013.10 recommendations were approved by the ASCRS Execu- As our understanding of diverticulitis has evolved, tive Council. In general, each ASCRS Clinical Practice so have recommendations for the clinical management Guideline is updated every 5 years. No funding was re- of these patients. Patients with diverticular disease are in- ceived for preparing this guideline and the authors have creasingly being treated as outpatients. Rates of admission declared no competing interests related to this material. to the hospital after emergency department evaluation for The terms uncomplicated and complicated divertic- diverticulitis dropped from 58.0% in 2006 to 47.1% in ulitis, symptomatic uncomplicated diverticular disease 2013.10 In addition, fewer patients are undergoing emer- (SUDD), and recurrent diverticulitis are used through- gency bowel surgery; the rate of patients undergoing an out this document. For purposes of this guideline, intestinal operation per emergency department visit for complicated diverticulitis is defined as diverticulitis as- diverticulitis decreased from 7278 of 100,000 to 4827 of sociated with uncontained, free perforation with a sys- 100,000 between 2006 and 2013.10 Concomitantly, there temic inflammatory response, fistula, abscess, stricture, has been an increase in the use of elective and laparoscopic or obstruction. Micro-perforation with small amounts surgery in the management of diverticulitis.11 of contained, extraluminal gas, in the absence of a sys- This publication summarizes the changing treatment temic inflammatory response, is not considered com- paradigm for patients with left-sided diverticulitis.
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