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Surgical management may lower QALYs in patients with recurrent diverticulitis
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Elective colonic resection surgery did not improve quality-adjusted life-years when performed after two episodes of diverticulitis. After three episodes of diverticulitis, quality-adjusted life-years were similar with surgical, conservative or medical treatment strategies. Rates of abdominal symptoms were lower in the patients that received the medical treatment strategy.
Results of a study recently published in Clinical Gastroenterology and Hepatology, conducted by Caroline S. Andeweg, MD, of the department of surgery, Radboud University Medical Center, Nijmegen, The Netherlands, and colleagues, suggested that management of chronic diverticulitis may be improved with less aggressive surgical management strategies.
For the study, researchers examined the primary outcome of quality-adjusted life-years (QALYs) for each of the following treatment strategies: colonic resection, conservative or medical treatments. The researchers used a Markov model to simulate patients with two episodes of diverticulitis that were not treated surgically. The model was then used to simulate the primary outcome for each of the different treatment strategies with a 1-year cycle length and a 10-year follow-up period. Morbidity, mortality, chance of colostomy formation, risk of recurrence and persistence of abdominal pain were all taken into consideration. Age-specific mortality rates were obtained from a Dutch mortality registry, and a search of Pubmed, Medline and Embase databases provided ranges for the sensitivity analyses.
Colonic resection after two episodes of diverticulitis was linked to the lowest quality-adjusted survival (a gain of 8.66 QALYs). It was also associated with the highest chance of stoma formation (1.1%) and the lowest chance of recurrence (mild, 3.5%; severe, 1.1%). All three strategies were comparable in terms of QALYs after 3 episodes of diverticulitis (colonic resection, 8.78; conservative, 8.76; medical treatments, 8.74).
“Evaluating the [quality of life], after [one] of [four] different treatment strategies in patients with recurrent episodes of diverticulitis in a decision analysis, we found that surgery after two episodes of diverticulitis resulted in the lowest QALYs. This was mainly caused by an early mortality risk related to the surgical procedure. In patients who had a third episode of diverticulitis, conservative, medical, and surgical treatment strategies are equal in terms of quality adjusted survival. Sensitivity analyses further confirmed that surgical resection and conservative or medical treatment after the third episode of diverticulitis are superior to surgical resection after two episodes of diverticulitis,” Andeweg and colleagues wrote in the discussion.
In an accompanying editorial, Marc S. Piper, MD, and Sameer D. Saini, MD, MS, both of the division of gastroenterology, department of internal medicine at the University of Michigan Medical School in Ann Arbor, said these findings should be “interpreted with caution.”
“First, this is a simulation model that is subject to a variety of underlying assumptions. Many of these assumptions, such as the long-term benefits and harms of medical therapy, remain somewhat uncertain,” they wrote. “Additionally, the model does not consider patient preferences, an essential factor when there is uncertainty about the best treatment option. That said, it does highlight the need for more nuanced case-by-case approaches in the management of recurrent diverticulitis.”
Disclosure: The researchers report no relevant financial disclosures.
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