A new study in the Annals of Surgery shows that immunosuppression stemming from solid-organ transplant is not associated with increased risk of recurrence or surgical complications for patients with diverticulitis.
“While transplant patients overall do face higher surgical risks compared with non-transplant patients, we did not find a higher risk of diverticulitis recurrence in this population,” said Vanderbilt University Medical Center’s Alexander Hawkins, M.D., M.P.H., director of the Colorectal Research Center.
Hawkins was the principal investigator on the study analyzing the national Merative MarketScan claims database to provide clearer guidance for colorectal practitioners and their patients.
“A patient may want a colectomy, but the decision has been a double-edged sword,” Hawkins said. “You want to help improve their quality of life, but you’re worried about higher surgical risks. We wanted to see if we could better quantify the risk of recurrence in this population.”
Previous single-center studies have painted an equivocal picture on the level of recurrence risk — and recent guidelines from the American Society of Colon and Rectal Surgery refer to “low-quality evidence” that supports current recommendations on sigmoid colectomy for this group.
Hawkins’ investigation had the primary aim of assessing acute diverticulitis recurrence risk, so the researchers compared recurrence rates and severity in patients with and without solid organ transplant experience. They found no differences.
“You can treat these patients like anybody else with diverticulitis, based on symptoms rather than concern over a high risk of future medical catastrophic recurrences.”
Further, when the data was adjusted to mitigate bias, they did not find significant differences in hospitalization, either.
“This supports the idea that you can treat these patients, whether through medical management or surgery, like anybody else with diverticulitis, based on symptoms rather than concern over a high risk of future medical catastrophic recurrences,” Hawkins said.
Population is Growing
The incidence of diverticulitis is rising, influenced by obesity rates, and it is affecting younger people. Add to that a rise in solid-organ transplants in the United States — a new record of more than 46,000 in 2023 — and the need to strengthen guidance around these issues becomes more urgent.
The colorectal surgical team at Vanderbilt performs well over 100 colectomies a year, many on an elective basis. Patients trade surgery — with its risk of potential infection and other sequela such as fissures and fistulas — for relief from painful flares that can persist for days and often require antibiotic treatment.
Because Vanderbilt performs more heart transplants than any center in the world, and is renowned for solid-organ transplantation overall, Hawkins says it is a natural locus for such research.
Equivalent Recurrence
In their study, Hawkins and his team identified 170,697 patients with acute diverticulitis, of which 170,255 had no history of solid-organ transplant. There were 442 organ recipients, with kidney and liver the most common. His team compared recurrence rates and hospitalization records 10 to 11 months later.
The primary outcome was recurrence of acute diverticulitis with the need for an associated antibiotic prescription at least 60 days from the initial episode.
“Based on what we knew going in, we had hypothesized that solid organ transplant patients would have a shorter time-to-recurrence and more severe episodes of recurrent diverticulitis when compared to patients without solid-organ transplants,” Hawkins said.
What they found, however, was that among patients who experienced recurrence, “complicated severity” did not rise to statistical significance after adjustment for bias.
Secondary outcomes included hospitalization, colectomy, and ostomy in patients with recurrence.
When patients were hospitalized for their recurrent episode, neither length of stay or discharge status were significantly associated with solid-organ transplant status.
Limitations and Conclusions
Study authors acknowledge limitations in the database, including the fact that all patients in the study had insurance — either privately or through Medicare, and that kidney-transplant patients were potentially underrepresented because Medicare does not cover this procedure.
“The decision to pursue colectomy in patients with solid-organ transplants parallels that of a non-transplanted patient.”
In the study, they wrote: “We do not support a universally low threshold for elective colectomy after successful medical treatment of acute diverticulitis in patients with solid-organ transplantation. Rather, we offer evidence to support the existing guidelines that the decision to pursue colectomy in patients with solid-organ transplants parallels that of a non-transplanted patient.”
“For the clinician, I think our findings also support shared decision-making, with each patient’s quality-of-life preferences front and center in the decision to medically manage or have surgery,” Hawkins said.
New Decision Tool
Hawkins is working to build a decision-making tool that helps clinicians make preference-driven decisions about colectomy. It would include subjective questions about flare frequency and even ask about patients’ biggest fears surrounding surgery.
“Diverticulitis is not like cancer, where you need to take it out,” he said. “It’s much more nuanced.”
Supplying input for this tool, Hawkins conducted a survey on patient opinions, including whether there were any regrets over having the colectomy.
“We’re really operating to improve quality of life,” he said. “Thinking about what that means for patients is our way of making sure that the right people are getting surgery and the right people are not getting surgery.”
