Persistent Symptoms After Elective
Sigmoid Resection for Diverticulitis
ORIGINAL
CONTRIBUTION
Bernhard Egger, M.D. Matthias K. Peter, M.D. Daniel Candinas, M.D.
Department of Visceral and Transplantation Surgery, University of Bern, Switzerland
PURPOSE: Despite technically successful surgery for
diverticular disease, a significant group of patients who
experience persistent or recurrent symptoms remains.
This study was designed to determine the incidence and
pattern of persistent symptoms and their association with
peroperative parameters.
METHODS: Follow-up (33 (range, 4–72) months) through
structured interviews with patients who had surgery for
diverticulitis in our department from December 1999 to
November 2004 was conducted. Of 162 patients, 124 (76.5
percent) were available for follow-up. Nonparametric tests
were used for comparison of patients who had undergone
elective (n=68) or emergency (n=56) procedures.
RESULTS: Of patients who had elective surgery, 25 percent
suffered persistent symptoms, including painful constipation, painful abdominal distension, abdominal cramps,
and frequent painful diarrhea. Neither the stage of disease
(complicated or uncomplicated) nor the surgical technique (laparotomy or laparoscopy) were significantly
related to the occurrence of symptoms. Recurrent
diverticulitis was not observed. Similar results were
obtained from comparisons with emergency patients.
CONCLUSIONS: The prevalence of persistent symptoms after
successful surgery for diverticular disease may be an
additional reason to carefully discuss the indication for
prophylactic surgery. In any case, preoperative counseling
and informed consent regarding the possibility of persistent
symptoms after prophylactic elective surgery is essential.
KEY WORDS: Diverticular disease; Diverticulitis;
Persistent symptoms; Recurrence; Sigmoid resection.
ost patients with sigmoid diverticulosis remain
asymptomatic throughout their lifetime and only
10 to 25 percent develop symptoms at some stage.1 The
most common clinical manifestations are related to acute
M
Presented at the Falk Symposium 148 on Diverticular Disease, Munich,
Germany, June 17 to 18, 2005, and published in part in a review/
extended abstract form In: Kruis W, Forbes A, Jauch K-W, et al. (eds)
Diverticular Disease: Emerging Evidence in a Common Condition;
Series: Falk Symposium, Vol. 148; 2006.
Address of correspondence: Bernhard Egger, M.D., Department of
Visceral and Transplantation Surgery, Inselspital, University of Bern,
CH-3010 Bern, Switzerland. E-mail: [email protected]
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diverticulitis and its complications, such as perforation,
abscess formation, fistulas, obstruction, and diverticular
hemorrhage. However, patients with proven diverticulosis
also may present with nonspecific abdominal complaints,
including lower left-sided abdominal pain, abdominal
distension, and irregular bowel habits. Such conditions
have been referred to as chronic diverticular disease2 or
smoldering diverticulitis;3 some authors have used the
term “symptomatic diverticulosis.”4 The multitude of
terms used for a wide array of clinical symptoms believed
to be associated in some form with sigmoid diverticula
reflects the diagnostic and therapeutic difficulties of this
condition and was the motivation for us to review our
own data with specific regard to long-term outcome.
In contrast to the acute complications of sigmoid
diverticulitis, the clinical signs of smoldering diverticulitis
may persist for years, often in the absence of significant
systemic or local inflammation.5,6 Symptoms might be
exacerbated by eating and diminished by defecation or
flatus, suggesting colonic wall distension because of raised
intraluminal pressure. Patients also might complain of
extensive bloating or severe constipation. However,
similar symptoms might be caused by irritable bowel
syndrome or various conditions that lead to chronic
constipation. Although functional disease often is a
diagnosis by exclusion, diverticula are clear morphologic
changes that are easily visualized and therefore tend to be
linked with persistent clinical symptoms. Furthermore,
there may be an overlap, often in a timely sequence,
between acute or recurrent diverticular attacks, smoldering diverticulosis, and irritable bowel disease.
The goal of surgical therapy for sigmoid diverticula of
all clinical forms is to achieve long-term cure defined as
normalized bowel habits, and the absence of abdominal
symptoms or recurrent diverticulitis. A critical review of
the current literature suggests that this goal is not
satisfactorily achieved. The rate of recurrent diverticulitis
after resection of the sigmoid colon ranges from 1 to 10
percent7–11 and, more importantly, up to 25 percent of
patients who receive surgery after two episodes of acute
diverticulitis experience persistent symptoms. This casts
severe doubt on the concept that elective surgery should
follow after two attacks of diverticulitis, as extensively
reviewed by Janes et al.12 In our study, we address the
question of persistent symptoms after sigmoid resection,
by comparing the long-term outcome after elective and
DOI: 10.1007/s10350-008-9234-3 VOLUME 51: 1044–1048 (2008) ©THE ASCRS 2008 PUBLISHED ONLINE: 1 MAY 2008
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review and telephone interview were analyzed with
medical statistics using Fisher’s exact (NCSS 2004,
Kaysville, UT).
Table 1. Modified Hinchey classification of acute diverticulitis
Stage
Characteristic
Ia
Ib
II
III
IV
V
Confined pericolic inflammation, phlegmon
Confined pericolic abscess
Pelvic, retroperitoneal, or distant intraperitoneal abscess
Purulent peritonitis
Feculent peritonitis
Fistula, obstruction, bleeding, immunosuppression after
transplantation
RESULTS
Of 162 patients undergoing surgery for diverticular
disease between December 1999 and November 2004,
124 (77 percent) were contacted for follow-up. The mean
follow-up time was 33 (range, 4–72) months. Twentythree (14 percent) patients had died (death was not
related to diverticular disease or its complications), and
15 (9 percent) could not be located. Of the 124 patients
included in the follow-up, the average age was 61 (range,
28–89) years, and 64 (52 percent) patients were men and
60 (48 percent) were women. All underwent abdominal
CT scans to diagnose diverticulitis. Furthermore, all
patients were operated on according to a standardized
intervention of rectosigmoid colon resection (>20 cm),
with mobilization of the splenic flexure and a lower
resection line in the proximal rectum. Sixty-eight patients
underwent elective surgery (study group: SG) and 56
patients underwent emergency operations (comparison
group: CG). According to the modified Hinchey classification, 73 (59 percent) patients had uncomplicated
diverticulitis (Ia, n=65 [52 percent]; Ib, n=8 [6 percent]),
and 51 (41 percent) patients had complicated diverticulitis (II, n=12 [10 percent]; III, n=17 [14 percent]; IV,
n=18 [15 percent]; V, n=4 [3 percent]). In the study
group (n=68), 64 (94 percent) patients had uncomplicated diverticulitis (Ia, n=59 [87 percent]; Ib, n=5 [6
percent]) and 4 (7 percent) had complicated diverticulitis
(II, n=2 [3 percent]; V, n=2 [3 percent]). Acute (60
percent) or chronic (40 percent) diverticulitis in the
resected specimens was confirmed by histopathology in
120 (97 percent) patients. In four (3 percent) patients (all
in SG), only diverticulosis with no inflammatory changes
emergency resections, and explore the association between stage or technical factors with persistent symptoms.
PATIENTS AND METHODS
Data were obtained from a consecutive database of all
patients undergoing colonic resection in our department.
All charts were reviewed for correctness of diagnosis,
demographics, and therapy rendered. The definition of
diverticulitis was based on the following clinical and
diagnostic findings: lower left quadrant pain, fever,
leucocytosis, consistent CT findings, and the need for
antibiotics. Disease severity was classified according to a
modified Hinchey classification (Table 1). Hinchey Stages
Ia and Ib were considered uncomplicated and Hinchey
Stages II, III, IV, and V were considered complicated.
After review, we attempted to contact all patients by
telephone. At that time, follow-up data from 124 patients
were obtained through telephone interviews. To analyze
the data, patients were classified into one of two groups:
elective surgery, or an emergency surgery comparison
group. Data about persistent abdominal symptoms,
recurrent diverticulitis (requiring antibiotics), bowel
function, scar pain, time to return to work, time to
resume (age-related) physical exercise, and general wellbeing regarding surgery and follow-up care (very well;
well; moderate; poor) were obtained. Results of the chart
Table 2. Demographic and surgical characteristics of patients with and without persistent symptoms
Patients (n=124)
All (n=124)
PS (n=30)
NS (n=94)
P value* PS vs. NS
Men
Women
Average age (yr)
Complicated diverticulitis
Uncomplicated diverticulitis
Surgery characteristics
Elective surgery
Emergency surgery
Two-stage surgery
Laparotomy
Laparoscopy
Specimen length (cm)
64 (52)
60 (48)
61.2 (28–89)
51 (41)
73 (59)
13
17
61
15
15
(43%)
(57%)
(43–89)
(50)
(50)
51 (54)
43 (46)
61.4 (28–86)
36 (38)
58 (62)
n.s.
n.s.
n.s.
n.s.
n.s.
68
56
35
86
38
17 (57)
13 (43)
9 (30)
23 (77)
7 (23)
20.2 (11–36)
51 (54)
43 (46)
27 (29)
63 (67)
31 (33)
19.6 (8–50)
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
(55)
(45)
(25)
(69)
(31)
PS=with persistent symptoms; NS=without persistent symptoms; n.s.=nonsignificant. Data are numbers with percentages or ranges in parentheses unless otherwise indicated.
*Fisher‘s exact test.
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Table 3. Demographic and surgical characteristics of study group patients with and without persistent symptoms after elective
sigmoidal resection
Patients (n=68)
All (n=68)
PS (n=17)
NS (n=51)
P value* PS vs. NS
Men
Women
Average age (yr)
Complicated diverticulitis
Uncomplicated diverticulitis
Surgery characteristics
Laparotomy
Laparoscopy
Specimen length (cm)
31 (46)
37 (54)
59.9 (28–81)
4 (6)
64 (94)
7 (41)
10 (59)
58.6 (43–75)
1 (6)
16 (94)
24 (47)
27 (53)
60.3 (28–81)
3 (6)
50 (94)
n.s.
n.s.
n.s.
n.s.
n.s.
32
36
19.4 (10–37)
9 (53)
8 (47)
18.2 (10–26)
23 (45)
28 (55)
20.4 (12–37)
n.s.
n.s.
n.s.
PS=with persistent symptoms; NS=without persistent symptoms; n.s.=nonsignificant. Data are numbers with percentages or ranges in parentheses unless otherwise indicated.
*Fisher‘s exact test.
was found. Complicated diverticulitis was the indication
for surgery in 46 (84 percent) CG patients (n=56).
Twenty-nine (54 percent) of these patients had bowel
discontinuity surgery (2: 7 protective ileostomies and 22
Hartmann procedures) with restoration of bowel continuity after approximately three months in all of them.
Thirty-eight patients (31 percent; SG: 53 percent) underwent laparoscopic intervention.
Two (1.6 percent) patients (both in CG) had
recurrent diverticulitis (diagnosed by CT scan), which
was successfully treated by antibiotics. Seventeen SG
patients (25 percent) and 13 CG patients (24 percent)
complained of persistent abdominal symptoms and
pain at the time of their last follow-up. The most
commonly reported symptoms were painful constipation
in 11 (36.7 percent; SG: 35 percent), painful abdominal
distension in 7 (23.3 percent; SG: 29 percent), abdominal
cramps in 7 (23.3 percent; SG: 4 percent), and frequent
painful diarrhea in 7 (23.3 percent; SG: 12 percent)
patients. At histopathology, all 17 SG patients with
persistent symptoms after surgery were proven to have
had acute (23 percent) or chronic (77 percent) inflammation in the resected specimens. Of the four patients
(all in SG) without proven acute or chronic inflammation, none complained of persistent symptoms or recurrent diverticulitis at follow-up. All patients with recurrent
diverticulitis or persistent abdominal symptoms were
treated by conservative means without additional
surgery. At the time of the telephone follow-up, patient
well-being regarding surgical intervention and follow-up
was very good for 63 (51 percent), good for 52
(42 percent), moderate for 8 (6 percent), and poor for 1
(1 percent) patient.
When we compared patients with persistent symptoms to those without these symptoms, no significant
differences were observed regarding sex, age, type of
surgery (2-stage only in CG), surgical technique (laparoscopy or laparotomy), or length of the resected colonic
specimen (Table 2). Similar results were obtained from
SG patients (Table 3). Furthermore, no significant
difference in persistent symptoms was found in all
patients when the interview results regarding resumption
of work and (age-related) physical activities, or incidence
of recurrent diverticulitis (2 CG patients), incisional
hernia, and scar-related pain were compared (results for
the SG patients are summarized in Table 4). However,
patients with persistent symptoms had a lower sense of
well-being compared with patients without persistent
symptoms (very well: 24 vs. 60 percent; well: 60 vs. 35
percent; moderate: 13 vs. 5 percent; poor: 3 vs. 0 percent).
In SG patients, similar results to that of the whole group
of patients were found regarding well-being for patients
with and without persistent symptoms (very well: 24 vs.
70 percent; well: 59 vs. 24 percent; moderate: 12 vs. 6
percent; poor: 6 vs. 0 percent). Additionally, there was no
difference in the incidence of recurrent diverticulitis or
scar pain in SG patients who underwent laparoscopy or
laparotomy. There also was no difference found when
comparing interview results regarding resumption of
work and (age-related) physical activities. Only the
incidence of incisional hernia was significantly different
for patients who underwent laparoscopy compared with
those who underwent laparotomy (Table 5).
Table 4. Interview results for study group patients comparing
presence or absence of persistent symptoms
All patients (n=68)
PS (n=17)
NS (n=51)
P value*
PS vs. NS
Resume work
(weeks)
Resume PA (weeks)
Recurrent diverticulitis
Incisional hernia
Scar pain
5.6 (2–12)
5.8 (2–12)
n.s.
7.5 (4–14)
0
2 (12)
2 (12)
7.2 (4–16)
0
5 (10)
4 (8)
n.s.
n.s.
n.s.
n.s.
PA=physical activity; PS=with persistent symptoms; NS=without persistent symptoms; n.s.=nonsignificant. Data are numbers with percentages or ranges in
parentheses unless otherwise indicated. *Fisher‘s exact test.
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Table 5. Interview results of study group patients (comparing
operative technique)
Elective surgery group
(n=68)
Laparoscopy
(n=36)
Laparotomy
(n=32)
P value*
Resume work (weeks)
Resume PA (weeks)
Recurrent diverticulitis
Incisional hernia
Persistent symptoms
5.7 (4.8–6.5)
7.3 (6.2–8.4)
0
1 (3)
7
5.9 (5–6.8)
7.3 (6.3–8.3)
0
6 (19)
10
n.s.
n.s.
n.s.
0.045
n.s.
PA=physical activity; n.s.=nonsignificant. Data are numbers with percentages or
ranges in parentheses unless otherwise indicated. *Fisher‘s exact test.
DISCUSSION
After successful sigmoid resection for the treatment of
diverticular disease, a significant group of patients still have
ongoing functional symptoms and pain. In the present
study, 25 percent of elective patients had persistent
symptoms, although surgery was performed only in
patients with recurrent, uncomplicated diverticulitis who
required antibiotics for each episode or patients with
complicated diverticulitis. Interestingly, patients receiving
surgery as emergencies (comparison group) have a similar
rate of persistent symptoms (24 percent). Our follow-up
results did not show any significant relationship between
disease stage (complicated or uncomplicated) or operative
technique (laparotomy or laparoscopy).
There is scant information in the literature concerning recurring or persistent symptoms that patients
experience after surgery. Thirty-five years ago, Parks and
Connell13 first reported on this subject. They found that
24 percent of patients treated with a three-stage procedure
continued to have mild symptoms. However, the symptoms were not well defined in the study. After elective
surgery, only a few studies, mostly retrospective, evaluated
functional postoperative results and none had CT-proven
diverticulitis.6,14–16 During a median follow-up time of 11
to 48 months after surgery, 7 to 27 percent of these
patients still experienced abdominal symptoms. The
authors attributed the reason for persistent symptoms to
coexistent irritable bowel syndrome,15,16 insufficient
length of the resected colon,15 or false indications for
surgery14 with no signs of inflammation. Interestingly,
another study by Moreaux and Vons,6 which reviewed
177 patients who had elective surgery, found that sigmoid
resection was successful in 82 percent of 77 patients
with chronic symptoms (n=46) but without signs of
inflammation. In our collective patient population, all
17 patients with persistent symptoms were found to
have had acute or chronic inflammation at histopathology
of the resected specimen. Furthermore, the length of
the resected colon was not different from that of patients
without persistent symptoms. Additionally, all of our
patients had at least two proven episodes of acute
diverticulitis prior to surgery. The prevalence of irritable
bowel syndrome may be up to 14 percent in patients
with diverticular disease.17 Therefore, preexisting or
associated irritable bowel syndrome may partially explain
the high rate of unsatisfactory outcomes. However,
associated irritable bowel syndrome does not explain
this outcome in 11 percent of our patients. Symptoms
may be associated with some ongoing, nonsystemic
inflammation5 or with postoperative adhesions. To clarify
this question, further studies are mandatory to evaluate
the functional outcome in patients undergoing colonic
resection for benign pathologies other than diverticular
disease.
Presently, several associations, including The American
Society of Colon and Rectal Surgeons (ASCRS)18 and the
Scientific Committee of the European Association of
Endoscopic Surgery19 recommend that elective prophylactic surgical resection be performed after two episodes of
uncomplicated diverticulitis. However, there is accumulating evidence in the literature that question this recommendation. Janes et al.12 recently reviewed the literature
and determined that there is no evidence to support this
recommendation. They found that, despite improved
medication and surgical techniques, surgery for diverticular
disease has a high complication rate, and a substantial
number of patients experience recurrent or persistent
symptoms after bowel resection. The obvious prevalence
of persistent symptoms after successful surgery for diverticular disease may be an additional reason to carefully
discuss prophylactic surgery with patients.
CONCLUSIONS
After successful elective surgical treatment of proven
diverticular disease, a significant group of patients who
have persistent symptoms that do not result from
recurrent diverticulitis remains. A coexisting irritable
bowel syndrome may partially explain this phenomenon.
Patients undergoing resection should be aware of this
potential problem. Preoperative counseling and informed
consent should include the possibility of persistent
symptoms after surgery. In all cases, patients should be
informed that surgery may not completely relieve their
symptoms. Considering the high incidence of persistent
symptoms after surgery for diverticular disease, surgeons
should be cautious about indications for surgery,
especially in patients with no proven episodes of acute
diverticulitis.
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