Episode 1 Journal Review - CCF colorectal
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[00:00:00] Hey everyone, and welcome to Behind the Knife. I'm Alyssa Deba, general Surgery resident at the Cleveland Clinic. And I'm Jared Hendron, another general surgery resident at Cleveland Clinic. And we're joined by members of our colorectal surgery team. My name is Dave Rosen. I'm the section head of colorectal surgery at Cleveland Clinic Fairview Hospital and joined by a couple of my colleagues on my incredible team here.

I'm ASU Khin. I go by aj, I'm one of the assistant professor at the Fairview Hospital, one of Dr. Partners. And I'm Joe Zo. I'm one of the associate program directors for the general surgery residency program here at the Cleveland Clinic and part of the West side Colorectal. All right, great. So the topic we're discussing today is the management of acute uncomplicated diverticulitis.

Why are we still treating these patients with antibiotics? There's been so many studies in randomized control trials showing no benefit, though we've been doing this for years. A 2022 study in Sweden found that only 11 to 48% of patients were managed without antibiotics at two [00:01:00] different hospitals. So clearly, many surgeons are still managing these patients with antibiotics.

But before we get into that debate on the literature, let's touch on diverticular disease as a whole. About 70% of patients developed diverticular disease by age 70. However, more recent studies show fewer than 5% of those with diverticulosis ultimately develop diverticulitis. Diverticulitis is still a highly prevalent disease in part just because of how common diverticulosis is in the general population, and it's one of the most common pathologies a colorectal surgeon manages In the US Data shows there are more than 2.7 million outpatient visits and 200,000 inpatient admissions.

Related to diverticulitis each year, which costs more than $2 billion. Most episodes of diverticulitis are uncomplicated with only about 12% of patients developing complications related to their diverticulitis. And the management of uncomplicated diverticulitis without antibiotics seems to be a pretty controversial topic.

Why do you all [00:02:00] think this is the case? So I think one of the problems is, you know, when we're dealing with a, a. Disease process that we tend to believe is an infectious process to treat it without antibiotics become somewhat challenging. And when you have a patient that comes in that's sick, who's that's ill, doesn't feel well and.

Basically telling them we're gonna treat this like a cold and we're not gonna treat 'em with any therapy other than just supportive career hydration. Especially if they've had previous bouts of it and have been treated in the past with antibiotics to feel like they've been treated better before. So sort of changing the thought process or the treatment pattern for patients is challenging.

And even for providers ourselves, it's, it's difficult to change what we normally are comfortable doing to see them better with this disease. I agree with Dr. Zo as he point, as he pointed out. I think some of the prob not problem, but some of the issues with the providers as well before we get called as colorectal surgeons.

They've already gotten antibiotics in the ed, they've gotten antibiotics from their primary care. [00:03:00] So I think there is a disconnect in terms of changing practice with other other providers compared to what is in our guideline. And I think some of our colorectal surgeons still haven't. Change as well.

So we definitely have that side of the table that has, that needs to be changed. Yeah. As my esteemed colleagues touched upon, I think a big part of the problem is getting our minds around the aspect of not giving antibiotics and part of it with diverticulitis is there's, there aren't too many diseases.

That are so prevalent that we know so little about. We manage this all the time, but the cause of it and the mechanism, the etiology of it, we don't completely understand. I think most people probably believe that there's a microscopic perforation with a episode of diverticulitis. And so if you were to have a micro perforation of the colon and bacteria and gas and stool leak out.

It's kind of a [00:04:00] no brainer thinking that in that infectious process, as Dr. Trusso said, you're gonna wanna treat with antibiotics. I think what we'll see when we get into these studies is a lot of these, I think a lot of these can be managed without antibiotics because the body is controlling. The perforation or the micro perforation antibiotics.

I try to, I way I wrap my head around is antibiotics are probably better for managing systemic infection, which might be similar, might be pretty low here. Similarly, if you are in the surgery in an, or doing a colon resection, you spill a little bit of stool, you kind of just clean it up and you don't give them extended antibiotics.

So I think really what the antibiotics are good for are systemic illness or sepsis and probably unnecessary in these. Localized uncomplicated cases. Great points. Let's go ahead and get into our journal review and case discussions, and we'll talk about whether or not we should continue using antibiotics for the management of uncomplicated diverticulitis.

Sure. So we'll start with the Dynamo study. This was a prospective multicenter, open label, [00:05:00] non-inferiority, randomized control trial, and 15 hospitals. In Spain with the primary endpoint being hospital admissions when comparing the treatment of uncomplicated diverticulitis with antibiotics versus just symptomatic management.

Secondary aims included differences in ed, revisits pain control and emergency surgery. Yeah, and the inclusion criteria were pretty strict for this study. Patients aged 18 to 80 were included if they had a modified NEF score of zero on imaging. No episodes of diverticulitis in the last three months. No antibiotic treatment in the last two weeks.

No significant comorbidities. Good symptom control in the ED and a max of one of the followings when looking at vitals and labs. Temperature greater than 38 Celsius or less than 36 Celsius, white count greater than 1200 or less than four 4,000. Heart rate greater than 90, respiratory rate greater than 20 or A CRP greater than 15.

Alright, y'all, let's start with a more straightforward [00:06:00] case. A 55-year-old female with hypertension, hyperlipidemia presents to the ED with mild but worsening left lower quadrant pain associated with nausea and chills in the ed. She is afebrile her white count's 14. Her other labs and vitals are within normal limits.

On exam, she's soft, non distended, and vocally tender to the left lower quadrant. CT of the abdomen and pelvis revealed sigmoid wall thickening with pericolonic fat stranding evidence of diverticulosis without evidence of abscess or perforation consistent with acute diverticulitis. Now, let's open the floor for the debate.

How would y'all manage your patients based on the Dynamo trial? So I think for this patient. This is a classic patient who would be a very good candidate to manage without antibiotics. You'll hear from Dr. Trunzo, my colleague here shortly as a counterpoint. And that guy loves causing c diff, so he would probably give this patient antibiotics.

But this patient fits within the criteria you see of the Dynamo trial. And this is a [00:07:00] patient who doesn't have any is not systemically ill, yes, has a leukocytosis. But the CT scan does not show any gross perforation, any free air anywhere. No reason to believe that this patient hasn't successfully walled off any type of micro perforation or disease process.

So I agree that, or I concede that it is difficult when a patient like this presents to the ER to resist the urge to not give antibiotics because the patient has had somewhat of a course that, or somewhat of a process that has caused them to come to the emergency department. But for a long time it was hard to.

Move away from open surgery to minimally invasive. And so it starts with us, Dr. Trunzo, if we're not willing to move the needle, who will? Well, I concede that I do put in my fair share of c diff patients in the hospital 'cause of my over antibiotic treatment. But to your point it is a challenge when these patients come to the emergency room and we are faced [00:08:00] with.

Radiographic findings of an infl inflammatory, most likely what we thought was an infectious process. And there's debate about that, but we know we're dealing with the perforation in many of these patients when they get complicated disease and have an abscess. We know there's a major infectious process going on here.

In this case, you have an uncomplicated episode of diverticulitis. I think Dr. Shinro made a comment about this many times. These patients have already. Been on treatment at home or by the time they've even called us to the emergency room to see the patient, they've already gotten a dose of antibiotics.

So it's, it's always challenging to turn around and say they're okay. Just send 'em home with no antibiotics and we'll have 'em check in with us in a couple of days to make sure they're proceeding without treatment. It's almost a knee jerk response at that point to continue with therapy and go forward with antibiotics to continue what likely has been started in the emergency room.

Yeah. Yeah. I believe Dr. Rosen and Dr. Tr both make excellent points. I think the way we can start to make changes [00:09:00] is by being very selective about patients. We are treating without antibiotics. For me, a patient without systemic symptoms, I think is a great way to start. And I think the Dynamo trial has a very conservative.

Criteria. So I think that's a good way to select patients. If a patient has incident finding of diabetic life, I think definitely don't treat antibiotics. And then again, if they have no systemic symptoms, that's a good patient to educate on. Diet, diet, dietary changes, and use of NSAIDs. However, if they have some other signs and symptoms, I think those are the patient that I would treat.

So we do have to educate patients and reassure them that even though they have some symptoms, it will get better over 24 to 48 hours with. Liquids and ibuprofen or toto or whatever you give. Okay. Let's discuss the Diablo trial. Now, this study was published in 2010, and it was a multicenter open label, pragmatic RCT, which aimed to assess the effectiveness [00:10:00] of the management for a patient's first episode of acute uncomplicated diverticulitis with or without antibiotic.

The study's primary outcome was time to recovery during six months of follow up, which was defined by discharge from the hospital, normal diet temperature less than 38 degrees Celsius and a VAS pain score below four without the use of pain medications, as well as resumption of pre illness working activities, which was assessed using a daily patient diary.

Yeah, so patients were included if it was their first episode of acute diverticulitis and limited to left sided diverticulitis. Modified HIE classification was obtained for all patients using a CT scan and only HIE one A or one B stages or arose mild diverticulitis stage were included. So before we get into our case discussion, I think it's important for us to define what complicated diverticulitis is.

How do y'all define complicated diverticulitis? For complicated [00:11:00] diverticulitis. I think already to establish things like stricture, fistulas and free perforation where you have free air, those are complicated. I think the subtlety in what we're discussing are the cases where it's inflamed and there's a bit of fluid around it.

An abscess, I think for me. Like that's what men Dr. Rose mentioned previously. If there's a micro perforation and just mild inflammation or significant inflammation, but there's no evidence of Flagg leg on the abscess, to me that's uncomplicated. But once you start to get a pretty significant reaction from the body where there's an abscess, I think to me that's complicated.

In addition to the stretches, the fistulas and free perforation.

Okay. Let's talk about another case, which isn't as straightforward and discuss how it relates to the Diablo trial. Let's say we have a 62-year-old man with hypertension, hyperlipidemia, COPD, and poorly controlled diabetes, who comes to the ED with [00:12:00] a temperature of 38 c, heart rate of a hundred white count 13 and left lower quadrant abdominal pain associated with nausea and diarrhea.

He's never had a history of diverticulitis and the CT showed sigmoid colon wall thickening with associated fat stranding and a two centimeter of pericolonic abscess in the setting of diverticulosis consistent with acute sigmoid diverticulitis, no other abnormalities on imaging. So what do you guys think?

Do you think this second patient has uncomplicated diverticulitis? And then how would you manage it? So you're giving me a challenging one here to try to argue against antibiotics, but I will do my best. No, I really can't. But this, for me, this is a complicated diverticulitis, right? The, for me, the def definition between hitchy one A and B is kind of where the line goes in terms of abscess formation for uncomplicated and complicated, right?

One A is a flag mont or localized inflammation. One [00:13:00] B being a pericolonic abs. Now, when you go through all of these trials, most of them would say most of 'em that would advocate for not giving antibiotics to uncomplicated diverticulitis. It's kind of the, the ideal patient, right? It's the patients that are healthy, don't have a lot of comorbidities, are not sick, don't have a lot of systemic findings.

Granted, you know, about 10% or so of the patients in the Diablo trial. Had HIE one B diverticulitis, so had complicated diverticular. So they did show, and granted, that's not enough of a subset to really show a statistically significant difference, but they had complicated diverticulitis included in this that they manage without antibiotics with success.

Now, this patient has poorly controlled diabetes, has COPD, has a lot of comorbidities. That would be, I think, really ill-advised to be the patient to manage without antibiotics. So I would call this complicated diverticulitis. And I'm glad you let me go first in this round because I can openly concede to Dr.

Rezo that in my practice, this [00:14:00] patient would need antibiotics. Yeah, I, I think this is one of those situations where it, it's you, you're gonna have a hard time seeing the risk or benefit of no antibiotics versus giving you benefit, leaving antibiotics in this scenario. There's just too many reasons why this particular patient may have a problem with non.

Medical therapy or mono aggressive, more aggressive medical therapy treats the antibiotics as being the aggressive or the more aggressive form of, of medical therapy. If you eliminate all the comorbidities, I still, I think for us as a surgeon, taking care of patients with absences, it's still a hard sell, even though.

This, the study did look at patients with small pericolonic absences and were able to be successful in that small cohort. It is very challenging to wrap my head around not giving any therapy aside from just supportive care. So I don't know, it's hard to debate this for me as a clinician.

And I think you're gonna have trouble [00:15:00] getting patients to buy into this as well. You have to sell this to them, that you're gonna be fine. That, you know, you're going to go on with no treatment, but, you know, these, these trials have been around this, this one particularly has been around for a long time and it has not gotten a lot of, i, it's still really not well adopted even after all these years.

It's been, you know, been around and available for us to review. To play devil's advocate, I would say in this study, in the d Avalo study, 3% of each arm required. Surgery. So can you make an argument that you can observe the patient and see what happens inpatient what, where only three of the 3% of them required surgery?

Yes, you can make that argument, but like Dr. Tru pointed out, I think for me as a clinician, it would be hard for me to sit on such a patient, especially someone with this, this many comorbidities. I don't wanna lose my window of treatment response to antibiotics. So I would definitely treat someone like this with antibiotics.

But I can [00:16:00] see the argument to observe such a patient, but in a very monitored setting. I definitely would not send this patient home to be observed at home that that would be, that'd be crazy. And not to keep belaboring it, the idea of bringing a patient to the hospital. Without treating with antibiotics would be a very difficult cell.

And then you start running into insurance related, well, what are you doing for the patient? Just hydrating the patient. Is that enough to get the patient in admission to the hospital? When you're not giving IV antibiotics, then it becomes a logistics issue as well. Hmm. That's a real life situation that you have to face with these patients.

So when you're admitting a patient to the hospital, it really is a tough cell to admit and do no antibiotic therapy. True. Yeah. So say you manage this patient without antibiotics and they haven't had any symptom improvement over the next couple days, would you go ahead and start antibiotics then? Well, let's make it not this patient, per se.

Maybe an uncomplicated diverticulitis, not with an abscess. The first patient that we talked about, someone that we all agreed could be managed reasonably with UN without antibiotic. So then to your point, what, what [00:17:00] Dr. Trel would you, what, how if the patient's not getting any better over the next couple days, do you wait a week?

Like how long do you wait before you start bother? I think four, eight hours is a reasonable target point to, to give the, and I, you know, I don't have a lot of data to support that timeline, but. I think after 48 hours, patients at that point are starting to have some frustration and it's like, I don't feel any better.

You don't want to give me anything at this point. So I think you're gonna have, you're gonna start losing the patient and they're trusting you if you're not doing anything for them and they're not feeling any better. And then obviously you always have to have that sort of window of if you feel like you're actually getting worse and they have to come back to the hospital and then start 'em, initiate them potentially.

Re-imaging them at that point, because now have you gone from an uncomplicated event when you first made the diagnosis to where now there's a pericolonic abscess that is formed. So I think you have to be, you have to have some line in the sand, whether it's 48 hours or 72 hours. I think educating the patient about what that timeline is too, setting an expectation with them [00:18:00] that we gotta give this a chance.

You gotta get them to buy into this therapy and say, look, at this point, if you're not feeling better, this is the next plan. Because if they know that, then I think you're gonna get more buy-in. If you're just kind of like. Sell 'em out there, they're gonna be fine. Without giving them some sense of what that threshold is, I think they're gonna run themselves into, you're gonna have some confusion and not an accepting patient of this sort of algorithm of treatment.

Yeah, I think, you know, 48 to 72 hours I agree, is probably about right. And again, the, I think getting, establishing the expectations for the patient is important. If they get worse over that time, maybe considering antibiotics if they're not getting better after 40 to 72, I think that's probably the time I would as well.

Of course. Like Dr. Rezo mentioned, if they're getting even more worse, you, they might need to bring it back in and get another CT scan and see how, see if something is developed. Yeah. Really fair points. So let's discuss our last case along with the VO trial, which was a clinical trial published in 2012 by the Dutch Diverticular Disease Collaborative Study Group.

This was a [00:19:00] multi-center randomized control trial in Iceland and Sweden that aim to determine if antibiotic therapy is necessary for patients with CT verified acute uncomplicated, left-sided diverticulitis. Their main outcome was recovery without complications at 12 months, and their secondary outcomes included complications, hospital length of stay, recurrence rates, readmission rates, and a need for surgery at 12 months.

And patients were included in the AVOD trial if they had acute left lower quadrant abdominal pain with tenderness indicative of diverticulitis temperature of 38 c or higher at admission or within 12 hours prior. An elevated white count or CRP and then CT confirmed left-sided acute uncomplicated diverticulitis with no abscess, free air fistula.

Let's discuss the management of this last patient based on the VOD trial and how it would guide management in general. Alright, so for our last case, we have a 70-year-old male with hypertension. Diabetes has lost A1C with [00:20:00] 7.5%. No signs of end organ involvement. History of prior episodes of diverticulitis treated with antibiotics complicated by a c diff infection, who presents with persistent fever.

So his temperature, you know, low grade, 100.2 degrees, heart rate 95, white count of 13 on exam. He's quite tender to the left lower quadrant, but not peritoneal. CT abdomen pelvis showed multiple rectal sigmoid diverticula associated with wall thickening and adjacent fat strain with an extra luminal foci of gas anterior to the sigmoid, but no free fluid was noted.

What do y'all think? Okay, so this scenario is interesting in that I've actually seen this in, in, in clinical practice. You know, patient has had multiple recurrent bouts of diverticulitis has now had issues with c diff. So treating with antibiotics becomes this. Very you have to be very cautious about when you are gonna trigger a patient for any treatment of antibiotics, for any type of infection.

So if you have an, a situation where we do have, [00:21:00] yes, there's a small extra luminal foci of gas, but if clinically speaking we can try to avoid antibiotics and potentially avoid the risk of another recurrent B of c diff, I think this might be that interesting case where you can consider doing it. And I think it is one of those things you have to be very cautious about keeping a close eye on them.

Yes, they have diabetes, some other health conditions, but if they're not you know, an extremis, I think this is a patient you might wanna really strongly consider being, avoiding antibiotics because the risk of c diff becomes sort of a whole nother algorithm. And actually this is one of those situations when I have patients that are running into issues with c diff after having recurrent bout of anti of diverticulitis that I'm.

Talking more forwardly about whether or not they should have definitive surgery because of this underlying risk of them being on and off antibiotics, treatments that are potentially gonna run them the risk of recurrent bouts of c diff. Yeah. So Jared and Alyssa, I didn't realize you guys were going to present an actual patient of Dr.

Zos that [00:22:00] he gave C Diff to with all his previous antibiotic use, but I think that's great that we're putting this on the air for everyone to see. I agree. I think this is a patient, you want to try to avoid antibiotics, right? But there are some comorbidities. Patient has diabetes, right? He's pretty tender, has a leukocytosis, low grade fevers.

So this is a patient actually, I would consider doing surgery on while inpatient, you know, because the patient is in a state right now where he's doing pretty well. But if his diverticulitis were to progress and become more of an issue. Then you have to say, okay, well as he gets, does he start getting septic?

Are you behind the eight ball? And then the surgery becomes one, almost guaranteed to have an ostomy and two become more difficult and a more prolonged recovery. So this one might be one that you involve the patient in. And I think probably what would sway me too is what were those prior episodes of diverticulitis like?

If you had previous complicated [00:23:00] episodes, I would probably especially be leaning more towards surgery, but I agree that antibiotics you try to be as avoid as much as possible. If he worsens and has you know, perforates or has an abscess, then you're talking about draining it and doing antibiotics, then you're gonna have a prolonged course.

So it might be one that, you know, depending on how the patient is and involving the patient discussion, I might do surgery on sooner rather than later. And this might be an indication of me being a junior partner and not as comfortable as Dr. Rosen and Dr. Zo. But for me, I'll have a hard time observing this patient for, you know, whatever time period you think in 24 hours to see if he needs surgery.

I personally will wanna put this gentleman on antibiotics, and I would rather give him, give him c diff treatment prophylaxis in addition to the antibiotics spread and observing and see what happens. But I definitely agree that the other men of c diff. Makes this someone that maybe a surgery should be thought of sooner rather than later.

If he feels medical management in my, in my situation, I would definitely operate this admission. However, if I can get into [00:24:00] outpatient, so I can do it electively, get his A1C a little better controlled, that would be my ideal preference. That's an interesting thought. Prophylactic c diff treatment in a setting where you feel like you need to treat them with antibiotics, what would you prefer?

What would you, your preferable. Treatment that you would use as prophylaxis for c diff pl vancomycin. Mm-hmm. Oral. Oral van. Yeah. I think that's a fair, I think that's a fair point. Yeah. That would be my preference. But yeah, these are all really great points and, you know, we've touched on this, but you know, in the age of multi-drug resistant organisms in these super bugs.

Being antibiotic steward as physicians is really important other than building the antibiotic resistance we're seeing. We also place patients at increased risk of c diff, like we talked about, and the much rarer, but possible risk of adverse effects like allergic reactions, SJS, stuff like that for patients that fit into these inclusion criteria.

The evidence from these randomized control trials has demonstrated that treating uncomplicated diverticulitis. With observation alone has proved [00:25:00] appropriate, but what about the patients that don't meet these exact conclusion criteria for these studies? Yeah, good point. Alyssa, maybe we can come to a final conclusion of sorts, when to prescribe antibiotics for these patients.

So for me, again, being the junior partner, I think I'll be a little more conservative in terms of patients. I don't treat with antibiotics, so for me, if a patient has incident, incident of finding of diabetic colitis, I would say that's fine. And then if they are otherwise healthy without any sign of signs of systemic symptoms, I think that's fine.

Even if they have some comorbidities, as long as they don't have any systemic symptoms, I think treating them without antibiotics is great. However if they have abs. You know, high white count, you know, concerning exam, I'm definitely admitting the patient, giving them antibiotics 'cause I don't wanna lose my window to treat them.

So of all the trials, I think for me dynamo has kind of the criteria that I would, I would like clinic, you know, in my clinical practice. And then, sorry, last comment. Definitely we need to, as collective surgeons drive the [00:26:00] change in the field and educate the other colleagues. Yeah, for me, I think that any patient with uncomplicated diverticulitis who does not have any signs of systemic illness is a good candidate to avoid.

Antibiotics. Now, if they have multiple comorbidities, you might think about, you know, otherwise, but I encourage everyone to not. Pretend they're, the comorbidities are more significant than they actually are as an excuse to give antibiotics. A little bit of hypertension is probably not a good reason to give antibiotics.

Saw our patient we talked about earlier with uncontrolled diabetes and COPD. Sure. I'm not trying to talk you out antibiotic on those, but I think also, you know, these patients really need, most of them, we touched upon it earlier, have been getting antibiotics for treatment of a lot of these episodes their entire life.

And it really takes some time to sit down and talk to 'em and explain the whole etiology and walk them through why you're not giving antibiotics. And I think it's important. A lot of times, you know, we're all busy, we got patients waiting we're running behind. There's an add-on case [00:27:00] we have to do. A lot of times it's a lot easier just to prescribe the antibiotics and get outta there three minutes earlier.

But I think we have to take it upon ourselves to really try to push the envelope. And you know, I am not saying you have to go cold Turkey once try with a couple patients when they do just fine. Recovering from their uncomplicated diverticulitis without antibiotics. You can let me know and then you can continue to push the envelope even further.

Okay. So I found that the, for someone who's been around doing this, you know, the non-antibiotic therapy has not been well adopted. But I just from our discussions alone and reviewing these cases for our discussion I feel like it is, is it is an underused tool, especially for these uncomplicated cases like Dr.

Rosen mentioned. And I think we need to be better stewards of this, you know, idea that we can be treating less of these patients with antibiotics and get a good result. And I think it, it's gonna take a sort of a collaborative effort with us and the patient and educating them that we are using this with good, you know, scientific support that we can [00:28:00] use this approach and, but I think it's still important to set some boundaries and some so where we are gonna start and stop treatment so that they know that we're not ignoring them, ignoring their symptoms, that we're actually doing this thoughtfully.

So. You know, with that I'd like to thank you all for listening in. That'll be the end of our discussion today. And thank you again for tuning in and dominate the day I.