The paper selected this month concerns the treatment of uncomplicated diverticular disease.
Long‐term follow‐up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis
Isaacson et al. BJS 2019. https://bjssjournals.onlinelibrary.wiley.com/doi/abs/10.1002/bjs.11239
Most of the recent publications on acute diverticulitis focus on the management of complicated disease; for example, laparoscopic lavage and the role of primary anastomosis. Whilst these are interesting and compelling topics, they do not reflect the majority of cases seen in clinical practice. It’s therefore refreshing to see a study looking at the treatment of uncomplicated diverticular disease.
The paper selected this month is the 10 year follow up of the AVOD trial. The AVOD trial ran in Sweden and Iceland between 2003-2010. This randomised 629 patients with CT proven uncomplicated diverticulitis to management with or without antibiotics. This follow-up cohort collected data on long term outcomes using health record data, and quality of life using EQ-5D 3L tool, in the Swedish trial participants. In short, the study shows low rates of complications in both groups at 11 years, and comparable quality of life.
Some caveats to the study include the use of administrative data for follow-up. There can often be inaccuracies in the dataset (compared to prospective, near patient collection). This may mean that data on subsequent treatments is missing, for example subsequent antibiotic treatment of acute diverticulitis. A single measurement of quality of life at 11 years might also be somewhat limited as it provides a snapshot, rather than data on trends over time. Some criticisms of the tool used (EQ-5D) include its generic nature, and use of the ‘3L’ tool might be argued as being less sensitive than the ‘5L’ version.
Should this affect our management of uncomplicated diverticulitis? In the context of a CT confirmed uncomplicated diverticulitis, with no focal peritonism, it appears safe in the longer term to manage without antibiotics.