Introduction

Colonic diverticulosis is a common, acquired condition characterized by the presence of mucosal and submucosal outpouchings at weak points in the muscularis propria where feeding blood vessels penetrate the muscle layer [1, 2]. Pseudodiverticula, which frequently occur in the sigmoid colon, vary in number and generally have a 5–10 mm diameter [3, 4]. Diverticular disease (DD) represents the fifth most important gastrointestinal (GI) disease in Western Countries in terms of direct and indirect healthcare costs with an estimated mortality rate of 2.5 per 100,000 per year [5]. The prevalence of diverticular disease increases substantially with age, and by the ninth decade, it affects almost 50% of the population [6,7,8]. DD is defined as diverticula associated with symptoms/complications, but not all patients suffering from DD have symptoms, and, in fact, the Rome consensus defined “diverticulosis” as the presence of diverticula in the absence of symptoms [9]. The symptoms associated to complicated diverticular disease are as follows: abscess, phlegmon, perforation, fistula, obstruction, and/or bleeding.

Although complicated diverticulitis associated with peritonitis (Hincey Classification Stages III and IV), fistula or obstruction, is a clear indication for surgical treatment, the optimal management for uncomplicated diverticular disease remains to be established. Guidelines recommending treating patients surgically (i.e., elective sigmoid resection) after two attacks of acute diverticulitis have been recently reconsidered and judged inappropriate and lacking cost effectiveness [10]. It has been amply demonstrated, moreover, that elective resection for uncomplicated diverticulitis does not alter disease outcome, nor does it decrease mortality or complications [11, 12]. In fact, according to recent studies, it would take 18 elective procedures to prevent a single emergency operation. It is clear then that surgery in the case of uncomplicated diverticulitis (with the exception of immunocompromised or young patients) does not aim to prevent another acute attack, but simply to improve the patient’s quality of life (QoL). According to recent guidelines, surgery, in fact, should be considered on a “case-by-case basis” also taking into consideration patients’ quality of life [13]. Until now, however, no validated, standardized instrument for DD has been available to assess patients’ well-being during the decision-making process. Spiegel and collaborators recently developed a new quality of life questionnaire, called the DV-QoL, that focuses on DD patients’ perceptions of their disease-related physical and psychological symptoms [14].

The current study aimed to assess the DV-QoL questionnaire in patients who underwent sigmoid resection for uncomplicated DD or who were prescribed pharmacological treatment in three Italian centers and to validate its use in this setting. The questionnaire’s relevance in managing this patient group was also assessed.

Methods

All the patients who underwent elective surgery in three Institutions (The Departments of Surgery and Gastroenterology University Hospitals in Padua, Trieste, and Udine) for uncomplicated diverticulitis during a 5-year period (2009–2014) were considered for inclusion in the study. All the patients considered for inclusion freely chose to undergo surgery because of symptoms compromising their quality of life. For comparison purposes, we also analyzed the data of consecutive patients admitted for diverticulitis during the same period who were treated conservatively (non-surgically) and a group of healthy volunteers.

In accordance with current practice, the diagnosis of diverticulitis was formulated on the basis of a clinical examination, blood tests, and radiological imaging findings. Study inclusion criteria included the following: left iliac fossa pain, leukocytosis, fever, radiological features of diverticulitis at CT scan; study exclusion criteria included the following: Hinchey III and IV [15], signs of fistula.

Information that was retrospectively collected from hospital records included the following: the type of diet the patient was following, smoking habits, alcohol consumption, bowel movements, number of previous attacks, disease extension, stenosis at bowel enema, CT scan or colonscopy findings, treatment with non-absorbable antibiotics (such as rifaximin), probiotics or mesalazine. Other information that was collected with regard to the surgical patients included the following: type of approach (laparoscopic or laparotomic), conversion to laparotomy, type of anastomosis (mechanical or manual), arterial section, early and late postoperative complications (anastomotic fistula, anastomotic stenosis, wound dehiscence, post-incisional hernia, urologic complications, other complications), days of hospitalization.

The surgically and non-surgically treated patients who satisfied the inclusion criteria were administered the DV-QoL and the 36-Item Short Form Survey (SF-36), a generic quality of life measure, by telephone twice: the first time (baseline), the patients were asked to respond to questions referring to their pre-treatment quality of life status; the second time, the patients were asked to respond to questions in view of their current (post-operative for surgical patients) condition.

The DV-QoL consists of four sections linked to four primary condition-related concepts (symptoms, concerns, emotions, behavioral changes); there are separate scores for each of these as well as a total score. The SF-36 consists of eight sections (physical functioning = PF, social functioning = SF, role limitation due to physical problems = RP, role limitation due to emotional problems = RE, mental health = MH, vitality (energy/fatigue) = VT, bodily pain = BP; there are separate scores for each of these as well as a total score.

Laparoscopic sigmoid resection: surgical technique

The procedure is normally performed as follows: after introducing a Hasson trocar using an open technique in the umbilical position, a pneumoperitoneum is created and the abdominal cavity is explored. Three other trocars are positioned: two in the right hypocondrium and the right iliac fossa and one in the subxifoid position. The colon is mobilized in a medial to lateral fashion, the Todt fascia is opened behind the inferior mesenteric vein, and the left ureter is recognized and preserved. Whenever possible, the inferior mesenteric artery is preserved, and a more peripheral vessel is sacrificed. If the inferior mesenteric artery must be sacrificed to manage the inflammatory mass, it is divided distal to the left colic artery. The splenic flexure is mobilized and the rectum is resected below the recto-sigmoid junction. The sigmoid colon is exteriorized through a suprapubic incision, and a mechanical terminal-terminal circular anastomosis is performed. The integrity of the anastomosis is verified by air-leak test.

Statistical analysis

Pearson’s correlations were used to compare the scores on the questionnaires of the two groups [14]. Student’s t test was used to analyze the baseline and post-treatment scores. Covariance analysis (ANCOVA) was performed to compare the variation in the pre- and post-treatment scores on the two questionnaires. ANCOVA was also performed to evaluate the improvement in quality of life in the surgical and non-surgical patients as far as the presence or absence of colonic stenosis and/or two or more hospitalization for acute diverticulitis was concerned. A p value of < 0.05 was considered statistically significant.

Results

One hundred and fourteen operated patients were considered eligible for the study: 97 agreed to participate and responded to the questionnaires; 17 were considered ineligible for the following reasons: ten patients declined to participate, one could not respond due to Alzheimer disease, and six patients had complicated diverticulitis. Sixty non-operated patients were considered eligible for the study: 44 agreed to participate and responded to the questionnaires; 16 were considered ineligible for the following reasons: 13 patients declined to participate, one could not respond due to Alzheimer disease, and two of the patients had a selection bias (one was operated after discharge from another city; the other was hospitalized for colonic hemorrhage). The data of 97 operated and 44 non-operated patients were analyzed (Fig. 1). We also analyzed the data of 44 healthy volunteers who were age and sex matched with the non-operated patients to validate the Italian version of the DVQoL.

Fig. 1
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Patient enrollment

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As shown in Table 1, the two groups of patients with diverticulitis were comparable for sex but not for age. No differences were found in the two groups with regard to the duration of symptomatic DD before hospitalization. The number of previous admissions for acute diverticulitis was comparable in the two groups. The surgical patients had a statistically higher frequency of stenosis (34.04 vs 9.37%) and of colonic stiffness (54.25 vs 17.24%) registered at imaging examinations with respect to their counterparts.

Table 1 The pre-treatment characteristics of the surgical and non-surgically treated patients
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Operative and post-operative data about surgical population are shown in Table 2.

Table 2 Operative and post-operative data of surgical population. IMA inferior mesenteric artery
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All the patients treated conservatively (non-surgically) were prescribed intestinal antibiotics such as rifaximin at discharge.

Translation validation of the DV-QoL

The Italian version of the DV-QoL (Appendix 1) was drafted by an English-Italian “bilingual” translator who translated the original English DV-QoL [14] version into Italian; the questionnaire’s backward translation into its original language format was carried out by another English-Italian “bilingual” translator and checked for inconsistencies with the original text. The patients’ responses to the DV-QoL were compared with their responses to the Italian version of the SF-36, a generic quality of life measure, to verify if the new questionnaire showed adequate measurement properties. Pearson’s correlation was used to analyze the statistical correlation between the two questionnaires (Table 3). The analysis uncovered a statistically significant correlation between the patients’ scores on the two questionnaires. It also demonstrated that the DV-QoL scores were able to distinguish between the DD patients and the healthy volunteers utilized as controls. Indeed, the overall and subscale DV-QoL scores in the patients and healthy volunteers were statistically significantly different (Table 4).

Table 3 Pearson’s correlation between items on the SF-36 and DV-QoL
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Table 4 Comparison of partial and total DV-QoL scores in the patient vs healthy volunteer groups
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Post-treatment quality of life

The surgically and non-sugically treated patients’ DVQoL and SF-36 scores referring to their pre-hospitalization QoL are outlined, respectively, in Tables 5 and 6. The patients who underwent surgical treatment had worse overall, pre-treatment DV-QoL scores with respect to the non-surgically treated patients. In particular regarding the scores pertinent to each item, concerns and behavioral changes were worse in surgical population, before treatment. The total SF-36 scores were not significantly different in the two patient groups (p = 0.1599).

Table 5 Comparison of partial and total pre-treatment DV-QoL scores in the surgical vs the non-surgical groups
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Table 6 Pre-treatment SF-36 subscale scores
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Post-treatment quality of life

The pre- and post-treatment scores on the DV-QoL and SF-36 of the surgical and non-surgical patients are outlined, respectively, in Tables 7 and 8. According to the global score and “concerns” and “behavioral changes” item scores on the DV-QoL, the surgical patients’ post-treatment QoL was better than that of the non-surgical patients. Scores on the “symptoms” and “emotions” items were not significantly different in the two groups. Considering the SF-36, no differences were found in the two groups on the post-treatment “General Health” item but the surgical patients had higher scores on the “Vitality” item with respect to the non-surgically treated patients.

Table 7 Post-treatment DV-QoL partial and total scores
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Table 8 Post-treatment SF-36 subscale scores
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Pre- and post-treatment variations in QoL scores

The differences in the pre- and post-treatment DV-QoL scores analyzed using ANCOVA were more marked in the surgical group (Table 9 and Fig. 2). Considering (Fig. 3), patients with worse basal QoL (in abscissa) presented a higher QoL improvement after surgery with respect to medical treatment.

Table 9 ANCOVA analysis of pre- and post-treatment variations in partial and total DV-QoL scores
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Fig. 2
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Variation DV-QoL final-basal, comparison between medical and surgical patients

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Fig. 3
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Variation DV-QoL (in ordinate) final basal between medical and surgical patients. From this graphic, it results that patients with worse basal QoL (in abscissa) present a higher QoL improvement after surgical treatment (the two lines move away)

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There were also statistically significant differences in the “physical functioning,” “Role limitations due to physical problems,” “vitality,” “Mental Health,” and “social functioning” SF-36 items. In short, the surgical patients had lower (worse) pre-treatment and higher (better) post-treatment scores with respect to the non-surgical patients on those items confirming that they perceived greater improvement on those SF-36 subscales. The variations in the global pre- and post-treatment SF-36 scores in the two groups were not statistically different (Table 10).

Table 10 ANCOVA analysis of pre- and post-treatment variations in subscale and total SF-36 scores
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Comparison of patients with and without risk factors

The DV-QoL and SF-36 were also used to assess the QoL of the surgically treated patients with regard to the presence or absence of colonic stenosis and/or two or more previous attacks. The analysis was carried out to examine if the patients with colonic stenosis and/or two or more previous attacks (the old guidelines for surgery in cases of uncomplicated diverticulitis) who underwent the surgical procedure show greater QoL improvement with respect to the patients without those features (Table 11). No differences in QoL improvement in the two groups were found with regard to this variable.

Table 11 ANCOVA analysis of pre- and post-treatment variations in DV-QoL and SF-36 scores with regard to the presence or absence of stenosis and/or two or more previous attacks
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Discussion and conclusion

Diverticular disease, which is characterized by uncomplicated and complicated forms, is defined by the presence of colonic diverticula with and without related symptoms/complications. While the indication for surgery is clear if the disease is complicated and there are signs of diffuse peritonitis (Hinchey classification 3 and 4), fistula, obstruction, and/or bleeding, it is unclear when the disease is uncomplicated.

Basing its recommendations on the description of clinical features found in the literature, in 2000, the American Society of Colon and Rectal Surgeons (ASCRS) proposed the following guidelines for elective surgery for diverticular disease: the presence of complications such as strictures or fistulas, two episodes of Hinchey type 1-II diverticulitis; one episode in young patients [16]. The rationale underlying those indications was the high risk of recurrence (33%) after every episode and of perforation as well as high rates of morbidity and mortality. It is also important to remember that the risk of a diverting stoma is much higher during emergency (56%) with respect to elective resections (15%) [17].

Several studies published after the year 2000 reported better prognosis in patients with recurrent diverticulitis. In a study by Chapman et al. who analyzed 337 patients hospitalized for complicated diverticulitis, 90% of the patients who died had no history of diverticulitis [18]. A long-term study on 25,058 patients admitted to the Seattle Hospital for diverticulitis found that 80.3% were treated conservatively; 19% of these had a second diverticulitis attack, but only 5.5% required subsequent, urgent surgery. Given these findings, several surgeons have changed their approach to the diverticular disease. Surgeons from Denmark and Scandinavia, for example, have abandoned recommendations for routine sigmoid resection following two episodes of diverticulitis and, instead, reserve elective sigmoid resection for patients with frequent recurrence of diverticulitis and for those with complications such as stenosis, fistulas, or persisting abscesses [19, 20]. According to recent German guidelines, patients with chronic uncomplicated diverticulitis (type 3b) should undergo surgery only after a careful risk/benefit assessment based on persistent/chronic symptoms during the disease-free interval (individual medical decision) has been made, and the general rule of elective interval surgery depending on the number of inflammatory episodes is no longer upheld [21]. Similarly in 2006, the American Society of Colon and Rectal Surgeons (ASCRS) changed its indications for elective surgery for uncomplicated diverticular disease; the number of attacks was no longer considered an indication for surgery. Instead the society recommended that the decision be made on a “case by case” basis [22] and underlined the importance of considering the disease’s impact on the patient’s quality of life when a surgical approach was being contemplated [23,24,25,26,27].

Given the nature and course of DD, it would be important to accurately evaluate QoL in these patients in order to select the best candidates for surgery. A specific questionnaire explicitly examining patients’ disease-related health condition would be a valuable instrument in this context. The DV-QoL is a relatively new instrument that was specifically developed to help physicians gauge patients’ gastrointestinal/QoL condition. While the SF-36 is a generic survey of patient health, the DV-QoL specifically examines physical and psychological aspects related to diverticular disease. A strict correlation between DV-QoL and SF-36 items was demonstrated in a study by Spiegel et al. [14] and was also confirmed by of the findings of the current study which aimed to validate the Italian version of the questionnaire.

The current study also aimed to utilize the DV-QoL to evaluate the quality of life of patients suffering from uncomplicated chronic symptomatic diverticular disease and to compare the results in surgically and non-surgically treated patients. Although the surgically treated patients had worse pre-treatment scores, they had better post-treatment global scores and scores on the “concerns” and “behavioral changes” items, a picture reflecting fewer disease-related preoccupations and a new behavioral approach. The surgically treated patients stated, in fact, “that they were no longer concerned about diverticular disease” because “the diseased part of the colon had been removed.” In addition, they were no longer concerned about the worsening of symptoms, nor were they fearful about new diverticulitis attacks. Finally, the patients pointed out they “no longer needed a special diet or a continuous therapy to prevent symptoms.”

A statistically significant difference was not found in the “physical symptoms” item of the DV-QoL in the two patient groups, a result that is consistent with the findings of Senapati A. who reported that surgery did not seem to improve pain in diverticular disease [28]. In fact, physical symptoms such as painful constipation, abdominal distension, and cramps could be due to the persistence of irritable bowel syndrome (IBS) already present before surgery or to ongoing non-systemic inflammation or postoperative adhesions, as was described by Egger et al. [29]. It is nevertheless important to remember that medical therapy could improve symptoms and prevent recurring attacks [30,31,32]. Although the absence of greater improvement in the “physical symptoms” item in the surgically treated patients is surprising, given the high frequency of stenosis (34.04%) and stiffness (54.25%) at radiologic imaging in these patients, it concurs with the finding that post-treatment variations in QoL were not significantly different as far as the presence or absence of stenosis was concerned. It could also be argued that if radiologic imaging is necessary for decision-making in patients with chronic diverticular disease, the Dv-QoL could provide some additional information regarding the disease’s impact on the patient’s QoL. As far as the SF-36 is concerned and in agreement with Scarpa M. et al.’s study [33], the patients’ overall general health scores were not significantly different in the two groups after treatment. Differences in the two questionnaires could in any case be explained by the fact that the SF-36 is not a specific questionnaire focusing on symptomatic uncomplicated diverticular disease (SUDD), but simply a standard instrument to investigate patients’ perceived general health.

It is important to point out that at the post-treatment assessment, some patients mentioned other new pathologies that were not present previously. Since the SF-36 is a generic instrument, it might not be able to discriminate between different pathologies and to gauge their impact on quality of life, despite the fact that we excluded patients with Alzheimer, a disease that could alter the patient’s perception of quality of life. Study results showed that improvement in quality of life was greater in the surgical with respect to the non-surgically treated patients, and the difference was more marked in the patients with worse pre-treatment quality of life (Fig. 3).

As far as the guidelines which recommend a tailored surgical approach for uncomplicated diverticulitis is concerned [24,25,26,27], we are convinced that quality of life should indeed represent an important decision-making element in view of the fact that, as demonstrated by our study, improvement in quality of life is an independent factor as far as colonic stenosis and/or number of previous attacks of acute diverticulitis is concerned.

The current study has several weaknesses: first of all, the questionnaires regarding the patient’s pre-treatment status were administered retrospectively; this may have created confusion between the two periods for some of the participants. Second, the two groups were not homogeneous: the non-surgical patients were older and this too could have created a study bias. Moreover, when the patients were asked to respond to questions regarding their pre-treatment health, the mean DV-QoL scores were higher (worse) in the surgically treated patients and, in fact, those patients showed a significantly higher frequency of stenosis (34.04 vs 9.37%) and colonic stiffness (54.25 vs 17.24%) at imaging. This difference seems to confirm the appropriateness of the current guidelines recommending surgery for patients presenting colonic stricture [34]. It is noteworthy that the patients with radiologic signs of stenosis included in this study underwent surgery electively for chronic symptoms and not for acute obstruction. Moreover, the Hinchey classification was used as our enrollment criteria because it is simple and widely utilized in the surgical field to evaluate patients. It would have been more appropriate to use the classification proposed by the German guidelines [21] to differentiate the types of chronic diverticular disease. The surgically treated patients enrolled in our study presented uncomplicated chronic symptomatic diverticular disease. Nevertheless, some patients with radiological signs of stenosis but without clinical bowel obstruction were included. According to the German Guidelines, these patients could be better described by type 3 b diverticular disease, and type 3 c, limited to the patients with radiological stenosis, while patients with fistula or conglomerate tumors (also included in the type 3 c according to the German Classification) were excluded.

The non-surgical group was less numerous than the surgical one studied because patients with acute uncomplicated diverticulitis are, in accordance with the current guidelines, generally treated as outpatients [35], and this too could have created another study bias. Finally, both questionnaires were conceived for self-administration, instead they were phone-administered.

To conclude, study results demonstrated that the DV-QoL accurately captured the well-being and psychological state of the DD patients studied before and after treatment. The study also showed that laparoscopic sigmoid resection improves the quality of life in patients with uncomplicated diverticular disease independently of the presence of colonic stenosis or the number of previous acute diverticulitis attacks requiring hospitalization. The improvement in the patients’ quality of life mainly regarded the psychological and behavioral fields, and in 95% of the cases studied, the patients expressed satisfaction with the improvement they experienced. The DV-QoL could be a useful complementary diagnostic instrument that could be used together with clinical and imaging findings to assess patients being considered for surgery. The decision to operate should, in fact, not only be tailored to the individual patient but also based on a multi-criteria analysis and on current guideline recommendations. Further perspective studies are, of course, warranted.

SSI surgical site infection