Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial

Wall, Bryan Joost Marinus van de; Stam, Marguerite A W; Draaisma, Werner A.; Stellato, Rebecca K.; Bemelman, Willem A.; Boermeester, Marja A.; Broeders, I. A. M. J.; Belgers, Eric J.; Toorenvliet, Boudewijn R.; Prins, Hubert A.; Consten, Esther C. J.

doi:10.1016/s2468-1253(16)30109-1

Cited by 129 publications

(116 citation statements)

References 33 publications

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“…Different authors have shown that in carefully selected patients, elective surgery improves the quality of life compared to conservative therapy, although obviously the risk of complications should always be considered [34-36]. Recent results of the direct-direct trial confirm this, showing that elective sigmoidectomy, despite its inherent risk of complications, results in better quality of life than conservative management in patients with recurrent and persisting abdominal complaints after an episode of diverticulitis [28]. …”

Section: Discussionmentioning

confidence: 99%

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

et al. 2018

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Background: Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection. Aims: The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis. Methods: During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years. Results: Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters. Conclusion: This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.

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Section: Discussionmentioning

confidence: 99%

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

et al. 2018

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“…Readmission rate for recurrent diverticulitis ranges from 9 to 25% [6, 8, 11-13] (Table 2). After a follow-up of 4 years, El Sayed et al [6], in an English study of over 65,000 patients managed nonoperatively for their first episode of diverticulitis, found the recurrence rate to be around 11.2%.…”

Section: Recurrent Diverticulitis: Risk Factorsmentioning

confidence: 99%

“…There is a move towards selective colectomy after one episode of uncomplicated diverticulitis on a background of recurrent acute diverticulitis. Quality of life is fast becoming the reason why patients choose to have, or not to have, elective sigmoid colectomy [11]. …”

Section: Treatmentmentioning

confidence: 99%

“…van de Wall et al [11] aimed to show, in the open-label randomized clinical DIRECT trial, which treatment modality had a better disease-specific and general quality of life measured by the Gastrointestinal Quality of Life Index (GIQLI) in patients presenting with either recurrent or persistent abdominal complaints after an episode of left-sided diverticulitis confirmed by CT, ultrasound, or endoscopy and followed for 6 months after a first attack of diverticulitis.…”

Section: Treatmentmentioning

confidence: 99%

“…This occurs despite complete remission and is a major economic burden amongst diseases of the gut. Additionally, 36% of people have ongoing abdominal symptoms after the first episode of diverticulitis [11-13]. As the incidence of diverticulitis increases, one would infer that recurrent attacks would begin to increase in frequency.…”

Section: Introductionmentioning

confidence: 99%

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Recurrent Acute Diverticulitis: When to Operate?

et al. 2018

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Objective: Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life. Methods: We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted. Results: Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity. Conclusion: Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.

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Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis

et al. 2021

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IMPORTANCE Diverticulitis has a tendency to recur and affect quality of life.OBJECTIVE To assess whether sigmoid resection is superior to conservative treatment in improving quality of life of patients with recurrent, complicated, or persistent painful diverticulitis. DESIGN, SETTING, AND PARTICIPANTSThis open-label randomized clinical trial assessed for eligibility 128 patients with recurrent, complicated, or persistent painful diverticulitis in 6 Finnish hospitals from September 29, 2014, to October 10, 2018. Exclusion criteria included age younger than 18 years or older than 75 years; lack of (virtual) colonoscopy or sigmoidoscopy data within 2 years, or presence of cancer, contraindication to laparoscopy, or fistula. Outcomes were assessed using intention-to-treat analysis. A prespecified interim analysis was undertaken when 66 patients had been randomized and their 6-month follow-up was assessable. Data were analyzed from June 2018 to May 2020. INTERVENTIONS Laparoscopic sigmoid resection or conservative treatment.MAIN OUTCOMES AND MEASURES The primary outcome was difference in Gastrointestinal Quality of Life Index (GIQLI) score between randomization and 6 months. RESULTSOf 128 patients assessed for eligibility, 90 were randomized (28 male [31%]; mean [SD] age, 54.11 [11.9] years; 62 female [69%]; mean [SD] age, 57.13 [7.6] years). A total of 72 patients were included in analyses for the primary outcome (37 in the surgery group and 35 in the conservative treatment group), and 85 were included in analyses for clinical outcomes (41 in the surgery group and 44 in the conservative treatment group). The difference between GIQLI score at randomization and 6 months was a mean of 11.96 points higher in the surgery group than in the conservative treatment group (mean [SD] of 11.76 [15.89] points vs −0.2 [19.07] points; difference, 11.96; 95% CI, 3.72-20.19; P = .005). Four patients (10%) in the surgery group and no patients in the conservative treatment group experienced major complications (Clavien-Dindo grade III or higher). There were 2 patients (5%) in the surgery group and 12 patients (31%) in the conservative treatment group who had new episodes of diverticulitis within 6 months. CONCLUSIONS AND RELEVANCEIn this randomized clinical trial, elective laparoscopic sigmoid resection improved quality of life in patients with recurrent, complicated, or persistent painful diverticulitis but carried a 10% risk of major complications.TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02174926.

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Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial

Cited by 129 publications

References 33 publications

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

Recurrent Acute Diverticulitis: When to Operate?

Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis

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