👤 Georgios Seitidis

The surgical management of complicated diverticulitis varies across Europe. EAES members prioritized this topic to be addressed by a clinical practice guideline through an online questionnaire. To develop evidence-informed clinical practice recommendations for key stakeholders involved in the treatment of complicated diverticulitis; to improve operative and perioperative outcomes, patient experience and quality of life through a systematic evidence-to-decision approach by a diverse, multidisciplinary panel. Informed by a linked individual participant data network meta-analysis of resection and primary anastomosis (PRA) versus Hartmann's resection (HR) versus laparoscopic lavage (LPL), a panel of general and colorectal surgeons, patient partners, trialists, and fellows appraised the certainty of the evidence using GRADE and CINeMA. The panel discussed the evidence using the evidence-to-decision framework during a synchronous consensus meeting. An asynchronous modified Delphi survey was used to establish consensus. The panel suggests that patients with complicated diverticulitis without sepsis receive PRA over HR or LPL when there is availability of a surgeon with skills and experience in colorectal surgery. HR is suggested over PRA or LPL in the subgroups of septic, frail, as well as immunocompromised patients. These recommendations apply to patients with an indication for surgery. Surgeons and patients should first consider conditionally recommended interventions, then conditionally recommended against. Based on the evidence, the key benefit of PRA was a higher likelihood of not having a stoma at 1 year, with similar risks across comparisons. Conditional recommendations call for shared decision-making when considering management options. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/7490 . This clinical practice guideline provides evidence-informed recommendations on the management of patients with complicated diverticulitis in accordance with the highest methodological standards through a structured framework informed by an international, multidisciplinary panel of stakeholders. Show less

We performed a systematic review and network meta-analysis (NMA) of individualized patient data (IPD) to inform the development of evidence-informed clinical practice recommendations. We searched MEDLINE, Embase, and Cochrane Central in October 2023 to identify RCTs comparing Hartmann's resection (HR), primary resection and anastomosis (PRA), or laparoscopic peritoneal lavage (LPL) among patients with class Ib-IV Hinchey diverticulitis. Outcomes of interest were prioritized by an international, multidisciplinary panel including two patient partners. Article screening, data extraction for IPD, and risk of bias appraisal were performed by two reviewers. We used a random-effects NMA to synthesize direct and indirect evidence. Heterogeneity was evaluated using the I Fourteen reports of seven RCTs were derived from 4,659 articles. IPD data were available for 595/678 patients (88.8%) across trials. Patients had a mean age ± SD of 64.61 ± 13.64 years and a mean BMI ± SD of 26.12 ± 5.20 kg/m PRA likely confers a lower stoma rate at 1 year compared to HR, while there may be no difference in 30-day/in-hospital mortality. LPL likely confers a higher in-hospital/30-day mortality rate compared to HR and PRA. Show less

There are many options for the surgical management of complicated diverticulitis, and standards vary widely despite international practice recommendations. We conducted a survey to capture the variation in practice across Europe. An online questionnaire was distributed to fellow and surgeon members of the European Association of Endoscopic Surgery (EAES) via email using the Opinio survey platform. Participants shared their demographic details. We asked members to rank the most likely intervention for patients with both stable and unstable Hinchey Class III, as well as Hinchey Class IV diverticulitis based on practice standards in their country. We used descriptive statistics, including counts and percentages, to characterize survey results. We created a heatmap to visualize the percentage of votes received for each intervention. We received 233 responses from surgeons and fellows across Europe from various countries, including Italy (35.6%), Greece (11.2%), and the United Kingdom (9.9%). Most members (79.4%) self-reported having expertise in colorectal surgery. For patients with stable Hinchey III diverticulitis, surgeons offered Hartmann's resection (HR) (41.6%), primary resection and anastomosis (PRA) (18.5%), laparoscopic peritonea lavage (LPL) prior to HR (16.9%), or LPL prior to PRA (15.5%), or LPL only (8.6%). In total, 31.4% of respondents offered LPL prior to sigmoid resection (HR + PRA). For patients with unstable Hinchey III diverticulitis, respondents offered HR (73.9%), PRA (3.85%), LPL only (6.84%), or LPL followed by sigmoid resection (15.4%). For patients with stable Hinchey IV diverticulitis, surgeons offered HR (71.7%), PRA (4.7%), LPL only (1.3%), or LPL then sigmoid resection (22.3%). Finally, for patients with unstable Hinchey IV diverticulitis, surgeons offered HR (83.1%), PRA (1.3%), LPL only (3.5%), or LPL followed by sigmoid resection (12.1%). Significant variation exists in the surgical management of complicated diverticulitis across Europe. Efforts must be made to increase the awareness and uptake of surgical guideline recommendations in clinical practice. Show less