Essential updates 2018/2019: Colorectal (benign): Recent updates (2018-2019) in the surgical treatment of benign colorectal diseases.

This review outlines current topics on the surgical treatment of benign colorectal diseases, with a focus on inflammatory bowel disease (IBD) and diverticulitis. Treatment options for IBD and diverticulitis have evolved in the last few years as a result of medical advances in technology and new clinical trials. Therefore, treatment options and strategies need to be updated to provide optimal care for patients. The purpose of this review is to elucidate recent global trends and update the surgical treatment strategy for IBD and diverticulitis based on literature published in the past 2 years. Prevalence of IBD, including ulcerative colitis and Crohn's disease, has increased over the last few decades. During this period, many new medical therapies were introduced for the treatment of IBD, including biological therapy, immunomodulators, and leukocyte apheresis therapy. As a result, new surgical strategies for IBD are required. In order to improve surgical outcomes in IBD patients, the influence of preoperative treatment on postoperative complications needs to be considered. The incidence of diverticulitis is also increasing with lifestyle changes and increasing numbers of older people. For diverticulitis with perforation and generalized peritonitis, surgery is the gold standard. Elective surgery after conservative treatment of diverticulitis is also an option because of high recurrence rates. With an increase in diverticulitis, systematic strategies are essential for an appropriate approach to diverticulitis, taking into account various factors, including the patient's background.

INTRODUCTION

In recent decades, the number of patients with inflammatory bowel disease (IBD) and diverticulitis has dramatically increased in developed countries.1, 2 Treatment options for IBD and diverticulitis have evolved over the last few years due to medical advances in technology and new clinical trials. Therefore, treatment options and strategies need to be updated to provide optimal care for patients. IBD refers to two distinct forms of disease, ulcerative colitis (UC) and Crohn's disease (CD), which are characterized by relapsing and remitting conditions and chronic inflammation in the intestine.3, 4 Development and/or pathogenesis of IBD is considered to be an inadequate immune response to luminal contents. New medical therapies have been rapidly introduced for the treatment of IBD, such as biological therapy, immunomodulators, and leukocyte apheresis therapy, among others.5, 6 Surgical treatments corresponding to these changes are also needed. In contrast, a diverticulum is a small outpouching from the intestinal lumen due mostly to mucosal herniation through the wall at sites of vascular perforation.2, 7 Diverticulitis is inflammation or infection of the diverticulum, which occurs mostly in the colon. In Japan, diverticulosis is increasing because of a widespread elderly population and changing lifestyle. Approximately 80% of patients with diverticulosis remain asymptomatic, and the other 20% of patients develop diverticulitis, requiring medical treatment.2

It is expected that the needs for surgical treatment of IBD and diverticulitis will increase in the near future with the increase in the elderly and prevalence. The present review highlights recent global trends and updates to surgical treatment strategies in IBD and diverticulitis based on the literature published in the last 2 years (2018‐2019). Several important studies are referred to as necessary information for surgeons. To facilitate understanding of the background of each procedure, papers published before 2017 were reviewed when applicable.

INFLAMMATORY BOWEL DISEASE

Inflammatory bowel disease is a chronic disease that causes unexplained inflammation in the gastrointestinal tract and comprises UC and CD. The number of patients is increasing globally, as well as in Japan.8, 9 Abnormalities in the gut immune system are thought to be highly involved in the development of IBD, but the exact pathogenic mechanism is unclear.2, 8 As both UC and CD often occur in young people and require long‐term treatment, they not only lower the quality of life (QOL), but hinder social activities, such as schooling, work, marriage, and childbirth. In addition, new problems, such as inflammation‐related carcinogenesis, have emerged with an increase in long‐term cases.10

Biological therapy based on disease mechanisms appeared in the 2000s. Patients’ QOL improved, and both medical treatment and surgical treatment changed significantly. A study of US patients between 2009 and 2015 showed that the use of biological therapy increased from 20% to 40% in CD patients, and from 5% to 16% in UC patients.11 Kimura et al12 showed that in 2011, Japanese patients treated with a biological preoperatively increased dramatically, and that in 2013, 41% of UC patients who underwent surgery had received biological treatment. Japanese nationwide cohort study also showed the rate of administration of anti‐tumor necrosis factor (TNF) increased from 0.3% in 2007 to 43% in 2017 among UC patients who underwent restorative proctocolectomy.13 Given the continuous emergence of biological therapies used more frequently in severe IBD, we are in a new era of biological therapy, including anti‐TNFα, anti‐interleukin (IL)‐12/23p40, anti‐integrin α4β7, and Janus kinase inhibitor, which will likely continue for some time. Assessment of variability in real‐world practice is essential to optimize the timing of initial therapy and surgery for IBD patients. According to a study of regional differences in the treatment of IBD after 2006, 66% of CD and 28% of UC patients in the USA commonly used biological therapy, compared to 19% of CD and 0% of UC patients in China. No differences were seen in the proportion of patients undergoing early surgery.14

With regard to surgical treatment, preoperative conditions in IBD are often immunosuppressive or patients are undernourished, and different from other bowel diseases, such as colorectal cancer. This section outlines points to be aware of in the surgical treatment of UC and CD.

Surgical treatment and biological therapy

Several reports, including randomized controlled trials, assessed preoperative treatment and surgical rates. The Active Ulcerative Colitis Trial (ACT) reported the efficacy of infliximab for induction and maintenance therapy and the cumulative incidence of colectomy in 728 patients with moderate‐to‐severe active UC. Patients receiving infliximab had a decreased Mayo score with decreased rectal bleeding compared to placebo patients. At 54 weeks of follow up, the colectomy rate was 10% in the infliximab group and 17% in the placebo group; which means the absolute risk of colectomy decreased by 7%.15, 16 Another study evaluated the short‐ and long‐term efficacy of infliximab in 45 patients with steroid‐resistant UC (24 infliximab and 21 placebo); 29% in the infliximab group and 67% in the placebo group underwent colectomy within 3 months, and 50% in the infliximab group and 76% in the placebo group within 3 years. No patient death was reported. Patients who had endoscopic remission within 3 months did not require colectomy, even after 3 years. The main benefit of infliximab occurred within the first 3 months, and early mucosal healing reduced the risk of subsequent colectomy.17, 18 The CONSTRUCT study showed the efficacy of infliximab and cyclosporine in 270 patients with steroid‐resistant UC. The colectomy rate within 3 years was 41% in the infliximab group and 48% in the cyclosporine group, and no significant differences were observed between the two groups.19 Laharie et al also reported the colectomy rates within 3 months for 115 patients with steroid‐resistant UC: 21% in the infliximab group and 17% in cyclosporine group. The 5‐year colectomy‐free survival rate was not different between the infliximab group and the cyclosporine group (65% vs 62%, respectively). Death directly related to UC or treatment was not observed.20, 21 A meta‐analysis showed short‐term clinical response rates in 72.1%, clinical remission rates in 52.4%, and 3‐month colectomy rates in 10.1% among patients receiving tacrolimus with moderate‐to‐severe and steroid‐refractory UC. No significant difference was seen for tacrolimus compared with anti‐TNF with regard to clinical remission rate, clinical response rate, and 3‐month colectomy rate.22 Narula et al reported the efficacy of anti‐TNF agents and calcineurin inhibitors including tacrolimus and cyclosporine for 314 patients with severe steroid‐refractory UC. Patients with sequential treatment achieved short‐term response in 62.4% and remission in 38.9%; however, the colectomy rates were high with 28.3% at 3 months and 42.3% at 12 months.23 Takeuchi et al24 also showed that tacrolimus and infliximab were equally effective in short‐term clinical remission and response rates, and in colectomy‐free rates for active UC.

Difference between the surgical approach and postoperative outcome was studied in 7070 patients with UC before (1995‐2005) and after the introduction of biological therapy (2005‐2013). The proportion of patients who underwent at least three procedures increased significantly in the post‐introduction group. Major events, procedural complications, and non‐routine discharge were also observed in the post‐introduction group.25 In Japan, reoperation rate in CD patients significantly decreased after the introduction of anti‐TNF agents in 2002. Risk factors for reoperation were preoperative smoking, perianal disease, and ileocolic‐type CD.26 A survey of UC patients from 2008 to 2013 reported the relationship between the introduction of biological therapy and surgery. The number of patients undergoing surgery decreased immediately after the introduction of infliximab and tacrolimus, but then increased again. Emergency surgery rates did not change throughout the study period.12

Surgical treatment

When emergency subtotal colectomy is carried out, we usually select i.p. placement of the closed rectal stump in order to prevent inflammatory adhesion at the next remnant rectal resection. Bedrikovetski et al carried out a systematic review of the appropriate management of rectal stumps after emergency subtotal colectomy in patients with acute severe UC. A total of 476 patients were assessed regarding closed s.c. placement of the rectal stump, i.p. placement, or mucous fistula formation. Pelvic sepsis rates were lowest (2%) in patients with s.c. placement. Patients with i.p. placement had less wound infection but high mortality.27 Risk factors in patients with chronic refractory UC were an absence of clinical response and lack of mucosal healing after induction with biological therapy. Early assessment (12‐16 weeks after therapy) of the clinical and endoscopic response could predict subsequent risk of colectomy.28

In CD, perianal lesions relapse the same as intestinal lesions, and exacerbation of lesions or inappropriate surgical treatment leads to decreased anal function and QOL. Selection of appropriate treatment is necessary for surgeons to maintain anal function. In 15 CD patients with complex perianal fistula, efficacy, safety, and feasibility of local administration of microfragmented adipose tissue were reported. During 24 weeks of follow up, 10 patients had remission, four patients improved, and one patient failed. No relevant postoperative complications or adverse events were observed. This procedure was minimally invasive with little risk of sphincter damage.29

With progress in medical treatment for IBD, surgical indications and prognosis have changed. The treatment effect should be evaluated early, and surgical treatment should be carried out before the general condition worsens without continuing with inadequate medical treatment for a long period of time.

Postoperative complications

Crohn's disease cannot be completely cured by surgery, and redo surgery for recurrence is often necessary. For efficient prevention of postoperative recurrence, it is essential to identify high‐risk cases of recurrence. The relationship between preoperative biological therapy and postoperative complications has been studied, but is still controversial. Gutiérrez et al studied early postoperative complications in 364 adult CD patients who underwent ileocolectomy with anastomosis; complications were observed in 27.5% of patients, mainly wound infections, intra‐abdominal abscesses, and anastomotic leakages. Complications were more common in patients with penetrating disease and those refractory to treatment, and urgent surgeries were associated with an increased risk of complications.30 Postoperative recurrence is a major problem in CD patients after ileocolectomy. Allez et al conducted a T‐cell receptor analysis of surgical specimens in 57 CD patients; clonal T‐cell expansion was associated with smoking. Clonal T‐cell expansion was also implicated in postoperative endoscopic recurrence, and highly clonal patients showed increased expression of genes related to CD8+ T cells.31 Introduction of immune cell evaluation would be key for appropriately predicting recurrence.

The effect of vedolizumab, a selective intestinal monoclonal antibody, on postoperative complications is still unknown. Law et al evaluated the impact of preoperative vedolizumab treatment on postoperative complications in IBD patients undergoing abdominal surgery. This systematic review included 307 patients in the vedolizumab‐treated group, 490 patients in the anti‐TNF treatment group, and 535 patients who did not receive preoperative biological therapy; preoperative vedolizumab treatment was not associated with an increased risk of postoperative complications compared to preoperative anti‐TNF treatment or no biological therapy in IBD patients.32 Yung et al reported that the risk of postoperative complications was not significantly different between preoperative vedolizumab and anti‐TNF in IBD patients. Particularly in UC patients, the risk of overall postoperative complications was lower in the vedolizumab group.33 Novello et al compared postoperative complications in 30 CD patients treated with ustekinumab and 73 patients treated with vedolizumab prior to colorectal surgery within 12 weeks. Choice of preoperative biologic therapy, ustekinumab or vedolizumab, did not influence postoperative complications.34 Another case‐matched analysis showed that exposure to preoperative vedolizumab was not associated with increased morbidity, but the majority of patients had an ostomy.35 The impact of biologicals on postoperative complications is still controversial. Summary of previous reports is shown in Table 1.23, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 Large prospective studies are required to draw conclusions.

Table 1

Impact of biologicals on postoperative complications

Author	Year	Disease	No. patients	Biologicals	Postoperative complications
Kopylov et al36	2012	CD	1641	TNF vs no Bio	Increased risk of postoperative complications
Billioud et al37	2013	IBD	4251	TNF vs no Bio	Increased risk of infectious complications in CD, Not associated with UC
Narula et al23	2015	IBD	4659	TNF vs no Bio	Increased risk of postoperative complications
Lau et al38	2015	UC	94	TNF vs no Bio	Not associated
Yamada et al39	2017	IBD	443	VEDO vs TNF vs no Bio	Not associated
Fumery et al40	2017	CD	209	TNF vs no Bio	Not associated
Kulaylat et al41	2017	UC	2476	TNF vs no Bio	Increased risk of postoperative complications in IPAA
Lightner et al42	2017	UC	146	VEDO vs TNF	Increased risk of SSI in VEDO
Law et al32	2018	UC	1332	VEDO vs TNF vs no Bio	Not associated
Yung et al33	2018	IBD	1080	VEDO vs TNF vs no Bio	Not associated
Novello et al34	2019	CD	103	UST vs VEDO	Not associated
Novello et al35	2019	UC	980	VEDO vs no Bio	Increased risk of postoperative complications in VEDO
Novello et al35	2019	UC	980	VEDO vs TNF	Not associated
Gutiérrez et al30	2019	CD	364	TNF vs no Bio	Not associated

Abbreviations: Bio, biologicals; TNF, anti‐tumor necrosis factor (TNF) agent; UST, ustekinumab; VEDO, vedolizumab.

Inflammatory bowel disease is associated with a 1.5‐ to 3‐fold increased risk of venous thromboembolism (VTE). Sarlos et al reported the risk of VTE during corticosteroid or anti‐TNFα therapy in 58 518 patients with IBD. VTE events occurred in 5.6% of patients. The corticosteroid group had a significantly higher incidence of VTE. In contrast, anti‐TNFα therapy had a fivefold lower risk of VTE compared to corticosteroids.43 Benlice et al reported the risk factors for 30‐day VTE from an analysis of 24 182 IBD patients after elective abdominopelvic bowel surgery. The 30‐day total and post‐discharge rates of VTE were 2.5% and 1%, respectively. Risk of VTE was associated with older age, steroid use, bleeding disorders, open surgery, hypertension, longer operative time, preoperative hospitalization, postoperative transfusion, and pelvic enterocutaneous fistula surgery.44

Hypoalbuminemia is a prognostic factor for postsurgical outcomes. Nguyen et al studied its role in predicting postoperative outcomes in 6082 CD and 4831 UC patients who underwent bowel surgery. Hypoalbuminemia was related to 30‐day mortality and infectious complications in both CD and UC patients, and was associated with extra‐intestinal complications, such as postoperative bleeding, cardiac failure, neurological failure, failure to wean off ventilators, VTE, and reoperation within 30 days.45

Positioning of surgical treatment

The LIR!C trial evaluated the cost‐effectiveness of laparoscopic ileocecal resection compared to infliximab in CD patients who failed more than 3 months of conventional immunomodulator or steroid therapy without signs of critical strictures. A total of 143 patients were included in this randomized trial, and total direct healthcare and social costs were lower in the resection group than in the infliximab group. Laparoscopic ileocecal resection is a cost‐effective treatment compared to infliximab.46 Murthy et al evaluated the impact of infliximab on hospitalization, surgery rates, and costs in IBD patients living in Ontario, Canada. The introduction of infliximab did not result in a significant reduction in hospitalization and surgery rates among CD patients, whereas the hospitalization rates declined substantially among UC patients. They reported a threefold increase in drug costs for CD patients following the introduction of infliximab, but no significant change in UC patients.47

The CONSTRUCT study showed the use of cyclosporine led to lower total costs compared to infliximab in UC patients. Nevertheless, no significant difference was found between these drugs regarding clinical effectiveness, colectomy rates, incidence of side‐effects, or mortality 1‐3 years post‐treatment. However, participants were more positive about infliximab than cyclosporine, and nurses disliked the i.v. cyclosporine. 19

In recent years, enhanced recovery after surgery (ERAS) has been shown to reduce length of hospital stay, complications, and costs after colorectal surgery, but the effect on IBD has been unclear. Liska et al reported an improvement in outcomes using ERAS in 671 IBD patients. Implementation of ERAS for IBD patients resulted in a decrease in length of hospital stay and costs without any increase in complications and readmissions.48

Robotic surgery for IBD has gradually spread, but the hybrid approach would currently be optimal for complicated cases.49 Mizushima et al50 reported that single‐incision laparoscopic surgery can be carried out safely in patients with stricturing or penetrating CD. In UC patients undergoing ileal pouch‐anal anastomosis, the 30‐day postoperative complication rate was comparable to laparoscopic surgery.51 The use of open, laparoscopic, and robotic surgery should be balanced with cost‐effectiveness and postoperative outcomes.

Bariatric surgery for IBD patients

In recent years, the relationship between obesity and IBD has attracted attention. Cañete et al studied the impacts of bariatric surgery on IBD. After bariatric surgery, 17 patients developed UC, 60 CD, and three unclassified IBD. Female gender (82%) was predominant, median age was 45 years, median BMI before surgery was 47 kg/m2, and 80% of bariatric surgery techniques were Roux‐en‐Y gastric bypass (RYGB). Potentially IBD‐related symptoms occurred within 1 month to 16 years after the surgery. Twenty‐four patients with UC, 35 patients with CD, and one patient with unclassified IBD underwent bariatric surgery. Sleeve gastrectomy (SG) was the most frequent technique and could be the procedure of choice in these patients.52 Heshmati et al showed the impacts of bariatric surgery in 31 CD patients and 23 UC patients; 19 patients underwent RYGB and 35 SG. There was a significant difference in the proportion of patients who had worsened CD after RYGB compared to SG (37.5% vs 4%). SG resulted in less weight loss but lower surgical complications compared to RYGB (26% vs 3%). In patients with IBD, especially CD, SG may be a safer surgical technique.53

DIVERTICULITIS

Diverticulitis of the colon is increasing in developed countries as a result of adaption of a Western lifestyle and an increased elderly population. Computed tomography (CT) is a useful method for diagnosing diverticulitis.7 Non‐complicated diverticulitis and diverticulitis with localized abscess are usually managed with conservative treatment. However, surgery or percutaneous drainage should be considered in a case with resistance to conservative treatment. Surgery is selected mainly for diverticulitis with perforation and generalized peritonitis.2, 7 Because recurrence of diverticulitis often occurs after conservative treatment, elective surgery should be considered. Herein, we describe the surgical treatment for diverticulitis.

Surgical approach

Safety and effectiveness of laparoscopic surgery for diverticulitis have been reported in recent years. According to a case‐control matching study, there was no significant difference in the complication rate, reoperation rate, readmission rate, and mortality between open and laparoscopic surgery. Laparoscopic surgery resulted in a shorter hospital stay and improved postoperative outcomes in patients with preoperative respiratory comorbidities. Between open and laparoscopic surgery for acute diverticulitis, no significant difference was shown in postoperative morbidity and mortality during short‐ or long‐term follow up.54, 55, 56 For diverticular disease, single‐incision laparoscopic surgery was equivalent to open sigmoidectomy regarding complications, but resulted in less pain, fewer blood transfusions, and shorter length of hospital stay.57

The use of robotic surgery for colorectal diseases has been reported in recent years. Ogilvie et al studied elective sigmoidectomy for diverticulitis, comparing laparoscopic and robotic surgery. Sixty‐nine robotic cases were propensity‐matched from a group of 222 laparoscopic cases; they found no difference in postoperative pain and length of stay, but total hospital costs were $15 000 higher for robotic surgery.58 Robotic and laparoscopic surgery were also compared in the elective management of left side diverticulitis. Robotic surgery was associated with shorter hospital stay (3.89 vs 4.75 days), lower conversion rate (7.5% vs 14.3%), and longer operative time (219.2 vs 188.8 minutes) than laparoscopic surgery.59 Cassini et al evaluated the effectiveness, potential benefits, and short‐term outcomes of 64 patients undergoing robotic surgery compared to 92 patients undergoing laparoscopic surgery for complicated diverticulitis. No conversions occurred in the robotic group compared to a 6.5% conversion rate in the laparoscopic group. Operative time, blood loss, hospital stay, and postoperative morbidity were not significantly different between the two groups.60 Raskin et al61 showed that the robotic‐assisted approach was associated with fewer conversions to an open approach, shorter hospital length of stay, fewer postoperative complications (ileus, wound complications, and acute renal failure), and more patients discharged directly to home compared to laparoscopic and open approaches.

However, most of these studies were reported from experienced facilities. The indication should be carefully determined by taking into account the skill of the surgeon and the patient's condition. Yeom et al reported the outcomes of laparoscopic surgery in patients with pan‐peritonitis. Postoperative complications occurred in 21.6%, and mortality in 4.8%. Preoperative shock (<90 mm Hg) and a longer time from symptom onset (over 2 days) to surgery were prognostic factors for postoperative mortality.62 Therefore, careful patient selections are necessary for laparoscopic surgery. Open surgery should be considered in cases with long duration from onset, cases with shock, cases with serious comorbidities, and/or cases with pan‐peritonitis.

Surgical procedure

Hartmann's operation has been carried out conventionally for complicated diverticulitis. The Hartmann operation has the challenge of stoma reversal and 30%‐40% of stoma cannot be closed.63, 64 Primary resection and anastomosis, and laparoscopic lavage are widespread as an alternative surgery. The LADIES trial assessed outcomes after Hartmann's procedure versus sigmoidectomy and primary anastomosis with or without protective ileostomy in 133 patients with severe sigmoid diverticulitis (Hinchey III or IV disease) aged <85 years. Twelve‐month stoma‐free survival was significantly better in patients with primary anastomosis, and no significant differences were observed in short‐term morbidity and mortality between the two procedures.65

Several studies have reported that primary anastomosis was similar to Hartmann's operation regarding major postoperative complications, mortality, and readmission rate.66, 67 However, Cauley et al68 reported that complication rates and in‐hospital mortality rates for primary anastomosis with diversion were higher than those for Hartmann's procedure. According to a review by Cirocchi et al, there is no significant difference in mortality and overall morbidity between primary anastomosis and Hartman's operation for perforated sigmoid diverticulitis with generalized peritonitis, although postoperative intra‐abdominal abscesses are fewer after primary anastomosis. Permanent stoma rates were not significantly different in these groups.69 Goldstone et al reported that postoperative mortality was twofold greater when general surgeons carried out a primary anastomosis compared to Hartmann's operation (7.4% vs 15%). Primary anastomosis by general surgeons was associated with postoperative complications and reoperation, whereas colorectal board certification was associated with decreased mortality.70

Several studies of laparoscopic lavage as an alternative procedure have been reported in recent years.71 The DILALA trial reported outcomes after laparoscopic lavage versus open Hartmann's procedure in patients with Hinchey grade III perforated diverticulitis. The proportion of patients who underwent one or more secondary operations within 24 months was lower in the laparoscopic lavage group (41.8%) compared to the Hartmann's procedure group (67.5%). The authors reported no difference in readmissions or mortality between these procedures.72 Penna et al also studied clinical outcomes after laparoscopic lavage or colonic resection in 589 patients with purulent diverticulitis. They reported no significant differences in mortality, 30‐day reoperation, or unplanned readmissions. The laparoscopic lavage group had more intra‐abdominal abscesses, peritonitis, and long‐term emergency reoperations, but this group had shorter operative time, fewer cardiac complications, fewer wound infections, and shorter hospital stay; 14% of patients in this group required a stoma.73 However, some reports found an association between laparoscopic lavage and increased morbidity, whereas laparoscopic lavage and other surgical procedures had comparable rates of early reoperation and postoperative mortality.74 Sneiders et al reported outcomes in patients treated with laparoscopic peritoneal lavage without sigmoidectomy for perforated diverticulitis with purulent peritonitis. More than 30% required additional surgery and readmissions; 31% of patients initially treated successfully had recurrent diverticulitis or other complications, and 22% of these patients eventually had a sigmoidectomy within 90 days.75

After Hartmann operation for diverticulitis requiring surgery, optimal timing of subsequent colostomy reversal remains unknown. Resio et al reported that early reversal (45‐110 days) is associated with patient age (≤60 years), ethnicity (Caucasian), and private insurance. Prolonged length of stay and 90‐day readmissions were significantly increased with late reversal, whereas mortality, transfusion, ileus, and major complications were not significantly associated with reversal timing.76 Open surgery, preoperative steroid use, and disease‐related factors were involved in ileostomy creation after primary anastomosis.77 Surgery for uncomplicated diverticulitis was also reported. Luu et al reported that both laparoscopic diverticulectomy and non‐operative treatment were safe and effective in patients with uncomplicated right‐sided colonic diverticulitis. Laparoscopic diverticulectomy could be an option in a case with possible recurrence.78

Postoperative complications and long‐term outcomes

The DIRECT trial showed significantly better QOL (less pain, lower risk of new recurrences) at the 5‐year follow up in patients who underwent elective sigmoidectomy compared to conservative treatment for recurring diverticulitis and/or ongoing complaints after an episode of diverticulitis. Forty‐six percent of patients with conservative treatment required surgery as a result of severe ongoing complaints.79 This trial also showed that elective sigmoidectomy is cost‐effective compared to conservative treatment.80

Risk factors and postoperative outcomes were evaluated in patients who underwent surgery for diverticulitis. Emergency surgery was associated with worse preoperative conditions and more postoperative complications, including mortality. Patients with comorbid conditions may be a better population for elective colectomy.81 An et al54 reported that preoperative serum albumin <3.0 g/dL affected the mortality rate. Varma et al retrospectively studied the timing of surgery in 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within 2 years. One‐fifth of patients underwent emergency resection, and median time from the initial episode to resection was 3.8 months for elective resections and 5.1 months for emergency resections. The odds of having an emergency surgery increased with every three passing months. Emergency surgery was also associated with more postoperative complications, 30‐day readmissions, and longer length of hospital stay.82 Lambrichts et al assessed the outcomes of non‐surgical treatment and identified risk factors for adverse outcomes in 447 patients with Hinchey Ib or II diverticular abscess. Treatment strategy, percutaneous drainage with antibiotics versus antibiotics alone, was not associated with short‐term treatment failure, emergency surgery, or long‐term surgery. Abscesses more than 3 cm were associated with short‐term treatment failure, and abscesses more than 5 cm were associated with the need for surgery.83

After surgery for diverticulitis, patients with metabolic syndrome (BMI >30 kg/m2, hypertension, and DM) had more adverse events, such as reintubation, ventilator dependence more than 48 hours, myocardial infarction, and superficial or deep surgical site infections. Patients with metabolic syndrome also had longer recovery and higher rates of complications, readmissions, and mortality.84 Bordeianou et al reported that 21% of patients with diverticulitis had surgical site infection. Obesity (BMI >30 kg/m2), advanced age (>70 years), diabetes mellitus, preoperative abscess, open surgery, emergency operations, and prolonged operations (>3 hours) were predictors of infection.85 Al‐Temimi et al compared surgically managed right side and left side diverticulitis. Patients with right side diverticulitis were more likely to be Asian and had a higher BMI than those with left side diverticulitis. Surgery for right side diverticulitis was associated with shorter hospital stay and less diverting stoma, but postoperative complications were not significantly different between right and left side disease.86

CONCLUSIONS

In the present review, we updated advancements in the surgical treatment of IBD and diverticulitis based on recent findings. The prevalence of these diseases will increase in the future as already seen in developed countries. Although surgical technology, including robotic surgery, is rapidly progressing, surgeons need to carry out the most appropriate treatment to prevent unfavorable outcomes for patients. Not only colorectal surgeons, but also general surgeons, should always keep in touch with these novel ideas and concepts to improve the QOL of patients.

DISCLOSURE

Conflicts of Interest: Authors declare no conflicts of interest for this article.