Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients

Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients Fabio Nocera, Fabian Haak, Alberto Posabella, Fiorenzo Valente Angehrn, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2939249/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Aug, 2023 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Weighing the perioperative risk of elective sigmoidectomy is done regardless of the specific diverticulitis classification. The aim of this study is to evaluate surgical outcomes according to the classification grade and the indication. Methods All patients who underwent elective surgery for diverticulitis between 2011 and 2020 were included. They were divided into two groups: relative surgery indication (RSI) and absolute surgery indication (ASI). RSI included microabscess and recurrent uncomplicated disease. ASI included macroabscess and recurrent complicated disease. Propensity score-matching (PSM, 1:1) was performed. Results Criteria for RSI were fulfilled in 585npatients and for ASI in 318. After PSM, 318 RSI vs. 318 ASI patients were selected; baseline characteristics results were comparable. The proportion of planned laparoscopic resection was 93% in RSI versus 75% in ASI (p<0.001), and the conversion rate to open surgery for laparoscopic resection was 5.0% and 13.8% in RSI versus ASI (p<0.001). Major morbidity (Clavien/Dindo ≥IIIb) occurred less frequently in RSI (3.77% vs. 10%, p=0.003). A defunctioning stoma was formed in 0.9% and 11.0% in RSI vs ASI, respectively (p<0.001). Conclusion The lower risk for postoperative morbidity, the higher chance for a laparoscopic resection and the decreased rate of stoma formation are attributed to patients with recurrent uncomplicated diverticulitis or diverticulitis including a microabscess as compared to patients with complicated diverticulitis or diverticulitis and a macroabscess, and this applies even after PSM. Knowledge of stage-specific perioperative risk is important in determining indications and counseling patients. Diverticulitis elective surgery surgical outcomes classification Figures Figure 1 Figure 2 Introduction In the past, the indication for elective sigmoidectomy after complicated or recurrent diverticulitis was justified by the expected risk of free perforation during recurrence [1, 2]. Based on more recent studies however, it is known today that the risk of perforation is highest at the first episode (5-25%) and decreases with the number of further attacks to less than 1% by the 5 th episode [3–5]. In addition, it has been found that recurrent episodes of diverticulitis neither lead to a higher complication rate nor to a higher failure rate of conservative therapy [6]. Based on these findings, the understanding of this disease has changed and the previously propagated recommendation for resection after the second inflammatory episode must therefore be considered obsolete [7–9]. Today, the indication for elective sigmoidectomy in diverticulitis must respect individual patient-related factors such as comorbidities and the impact on quality of life. This is highlighted in particular by two recent published studies: The multicenter DIRECT trial such as the LASER trial demonstrated both in a randomized setting better results in quality of life comparing laparoscopic elective sigmoid resection with conservative treatment in patients with recurrent and persisting abdominal complaints. Both support surgery despite inherent risk of complications of operative management [10, 11]. Clinical guidelines for diverticulitis aim to use diagnostic methods and therapeutic strategies in a reasonable way, avoiding under- or overtreatment. Common across all guidelines is the assessment of the risk versus the benefit of the surgery and accordingly either recommend an operation or not [9, 12, 13]. However, none of these guidelines stratify the actual risk of surgery according to the classification of the diverticular disease or the severity of the disease. In addition, which specific groups of patients would benefit from elective surgery or at what time these patients should be operated on are questions that continue to be debated due to a lack of evidence-based data [14]. This may lead to different or misleading decision-making for elective surgery in the individual situation. For these reasons, the aim of this study is to evaluate the surgical outcomes according to the different severities of indications, which considers the risk of the intervention, i.e., the morbidity of the surgery and the severity stadium of the disease. The evaluation of these different severities of indications enables us to stratify the specific risk of each classification grade and/or indication severity and helps us to achieve a more patient-related assessment, allowing us to perform better benefit-risk counseling. Methods Patients All patients who underwent elective sigmoid resection for diverticulitis, as defined according to clinical and radiological diagnosis, between January 2011 and March 2020 at the University Center for Gastrointestinal and Liver Disease Clarunis (Basel, Switzerland) were included in this study. The preferred approach in all patients was laparoscopic surgeries if not contraindicated. Sigmoidectomy was performed using a central dissection with resection of the inferior mesenteric artery or by peripheral dissection according to surgeon’s preference. The patients were divided into two groups based on the severity of the surgical indication. The severity has been evaluated by the German guidelines and the German classification system CDD (classification of diverticular disease) (Table 1 ) [ 9 ]. Elective sigmoidectomy has a strong indication in patients with stenosis or fistula (CDD Type IIIc) and should be offered in patients with conservatively/interventional treated macroabscess (CDD Type IIb) (Fig. 1 ). The less strict indication in contrast, considers patients with “milder” complaints, such as patients with recurrent uncomplicated diverticulitis (CDD Type IIIb) and patients with conservatively treated microabscess (CDD Type IIa) (Fig. 1 ). Due to these indications, patients were divided into a relative surgery indication group (RSI) and an absolute surgery indication group (ASI). RSI included recurrent uncomplicated diverticulitis (CDD IIIb) and surgery after complicated acute diverticulitis with a microabscess (CDD IIa). ASI included surgery after complicated acute diverticulitis with a macroabscess (CDD IIb) and patients with a complicated chronic diverticulitis with stenosis or fistula (CDD IIIc). Table 1 – Classification of diverticular disease (CDD) according to the German S2k guideline [ 9 ] Term Synonym Definition CDD Type Asymptomatic diverticulosis Identification of diverticula in colon 1 0 Acute uncomplicated diverticulitis Diverticulitis without perforation* 2 Diverticulitis with phlegmonous Ia Diverticulitis with phlegmonous peridiverticulitis Ib Acute complicated diverticulitis Diverticulitis with covered perforation Microabscess ( 1cm) IIb Free perforated diverticulitis Purulent peritonitis IIc* 1 Fecal peritonitis IIc* 2 Chronic diverticular disease Symptomatic uncomplicated diverticular disease (SUDD) Typical clinical features* 3 IIIa Relapsing diverticulitis without complications Recurrent signs of inflammation IIIb Relapsing diverticulitis with complications Identifications of stenoses, fistulas, conglomerate tumor IIIc Diverticular bleeding Identification of source of bleeding IV Exclusion criteria were emergency surgeries. The Ethical Committee of Northwestern Switzerland approved the study, and all eligible patients provided general informed consent (EKNZ Nr. 2018 − 00318). Table 2 – Recommendation regarding elective sigmoidectomy by different national and international guidelines [9, 12, 13, 28–31] Table 1: ● = recommended, ○ = not recommended, * = to consider, - = not discussed, 1=pelvic abscess treated by means of percutaneous drainage due to the poor long-term outcomes of conservative treatment, 2 = in specific clinical situations (persisting symptoms and signs, degree of diverticulitis) DGVS/DGAV: German Society for Gastroenterology, Digestive and Metabolic Diseases/German Society for General and Visceral Surgery WSES: World Society of Emergency Surgery ESCP: European Society of Coloproctology SICCR: Italian Society of Colorectal Surgery NSS: Netherlands Society of Surgeons Data collection Data from enrolled patients were included prospectively in an institutional study register database. Records were analysed retrospectively for demographic data such as age, gender, body mass index (BMI), American Society of Anaesthesiology (ASA) classification, previous intraabdominal surgeries, classification of diverticular disease (CCD), recurrent diverticulitis, number of recurrences, preoperative colonoscopy, preoperative symptoms and co-morbidities (arterial hypertension, coronary artery disease, immunosuppression and diabetes mellitus), surgical data such as surgery time (skin incision to wound closure), intraoperative complications, conversion rate to open surgery, type of access, type of anastomosis and specimen extraction technique, postoperative data such as overall morbidity according to Clavien-Dindo [ 15 ], minor morbidity (Clavien-Dindo < IIIb), major morbidity (Clavien-Dindo ≥IIIb), anastomotic leaks, mortality, comprehensive complications index (CCI) [ 16 ], number of defunctioning stomas (Hartmann procedure, planned and unplanned) and number of stoma reversals. Complications were defined as any type of deviation during surgical procedure or postoperative course. In order not to miss a recording of any complication, the recording of the complications was carried out in duplicate form in which the resident physician records the complication, and the head surgeon supervises and confirms or corrects the recording. Anastomotic leaks were diagnosed by computer tomography and/or endoscopy in cases of clinical suspicion, depending on the surgeon’s preference. A patient could suffer from more than one complication, and thus, their total number could be higher than the number of patients with complications. Statistics analysis Continuous data were summarized by using mean and standard deviation (SD) for normally distributed data, or medians and interquartile range for non-normally distributed data. Student’s t-test or Mann-Witney were used to compare differences, as appropriate. Categorical variables were summarized using counts and/or percentages and were analysed with Fisher’s exact test or Pearson’s Chi-squared test. A p-value < 0.05 was considered statistically significant. To control for potential confounders, a propensity score was generated for each patient from a multivariable logistic regression model based on key co-variables (age, BMI, arterial hypertension, coronary heart disease, immunosuppression and diabetes) as independent variables with relative or absolute indication for elective surgery as a binary dependent variable. Those baseline variables in the univariate analysis with a p value < 0.1 or otherwise of specific clinical interest were added to the model. Each patient with relative indication was matched with replacement to one patient with absolute indication in a 1:1 ratio, with a caliper width of 0.20 standard deviation of the logit of the propensity score using R statistical software version 2.13.1 using package “MatchIt” [ 17 ]. The quality of the match was assessed by comparing the patient characteristics before and after matching as shown in Table 3 . Data in the matched data set were analysed using a generalised random block design for continuous variables and conditional logistic regression for categorical variables. Table 3 – Demographic data of patients in the RSI and ASI group Unmatched (n = 903) Propensity score matching (PSM) (n = 636) RSI-G n = 585 ASI-G n = 318 p-value RSI-G n = 318 ASI-G n = 318 p-value Age in years (median, IQR) 62 (36–92) 67.7 (26–87) < 0.001 67.6 (43–86) 67.7 (26–87) 0.892 Gender (N, %) Male Female 233 (39%) 352 (61%) 122 (38%) 196 (62%) 0.721 108 (34%) 210 (66%) 122 (38%) 196 (62%) 0.283 Body mass index kg/m 2 (median, IQR) 26.6 (14.8–45.4) 26.6 (16-48.3) 0.768 26.4 (14.8–45.4) 26.6 (16-48.3) 0.628 ASA-Score (N, %) 1–2 3–4 115 (80%) 28 (20%) 63 (61%) 40 (39%) < 0.001 52 (83%) 18 (17%) 63 (61%) 40 (39%) 0.1 Previous intra-abdominal surgery (N patients, % of patients) 316 (54%) 169 (53%) 0.834 181 (57%) 169 (53%) 0.381 Classification of diverticular disease (CDD) (N, %) IIa IIb IIIb IIIc 80 (14%) 0 505 (86%) 0 0 79 (25%) 0 239 (75%) 38 (12%) 0 280 (88%) 0 0 79 (25%) 0 239 (75%) Recurrent diverticulitis (N patients, %) 544 (93%) 224 (70%) < 0.001 298 (93%) 224 (70%) 6 35 (8%) 188 (45%) 181 (43%) 16 (4%) 40 (37%) 50 (45%) 20 (18%) 0 < 0.001 < 0.001 0.915 < 0.001 0.059 16 (7%) 99 (45%) 98 (44%) 8 (4%) 40 (37%) 50 (45%) 20 (18%) 0 < 0.001 < 0.001 1.0 < 0.001 0.056 Preoperative coloscopy (N, %) Normal Inflammation Chronic-sclerosing Fixed loop/Kinking Stenosis Fistula 390 (67%) 339 (86%) 13 (4%) 23 (6%) 15 (4%) 0 0 206 (65%) 42 (20%) 10 (5%) 33 (16%) 21 (10%) 97 (47%) 3 (2%) 0.609 < 0.001 0.376 < 0.001 0.004 < 0.001 0.043 212 (67%) 182 (86%) 7 (3%) 14 (7%) 9 (4%) 0 0 206 (65%) 42 (20%) 10 (5%) 33 (16%) 21 (10%) 97 (47%) 3 (2%) 0.676 < 0.001 0.466 0.006 0.038 < 0.001 0.119 Preoperative symptoms (N, %) Pain Fever Constipation Diarrhea Stool irregularities Haematochezia Nausea Urogynaecology symptoms General condition deterioration 273 (46%) 20 (3%) 46 (8%) 28 (5%) 46 (8%) 4 (1%) 11 (2%) 4 (1%) 15 (2%) 160 (50%) 12 (4%) 61 (19%) 36 (11%) 51 (16%) 5 (1.5%) 31 (10%) 26 (8%) 19 (6%) 0.297 0.851 < 0.001 < 0.001 < 0.001 0.292 < 0.001 < 0.001 0.016 153 (48%) 11 (3%) 25 (8%) 12 (4%) 26 (8%) 3 (1%) 7 (2%) 1 (0%) 10 (3%) 160 (50%) 12 (4%) 61 (19%) 36 (11%) 51 (16%) 5 (1.5%) 31 (10%) 26 (8%) 19 (6%) 0.634 1 < 0.001 < 0.001 0.003 0.725 < 0.001 < 0.001 0.127 Co-morbidities (N, %) Arterial Hypertension Coronary heart disease Immunosuppression Diabetes 185 (32%) 22 (4%) 20 (3%) 27 (5%) 115 (36%) 23 (7%) 22 (7%) 25 (8%) 0.183 0.025 0.021 0.052 114 (36%) 19 (6%) 18 (6%) 17 (5%) 115 (36%) 23 (7%) 22 (7%) 25 (8%) 1 0.632 0.625 0.264 Results In the study period, a total of 998 operations for diverticular disease were performed at the University Center for Gastrointestinal and Liver Disease Clarunis (Basel, Switzerland). 95 patients were excluded due to exclusion criteria. The remaining 903 patients were analysed in context of this study. In the univariate analysis, 585 patients were assigned to the RSI group and 318 patients to the ASI group. After propensity score-matching (PSM) was applied, 636 remained for analysis, 318 patients for each group (Fig. 2 ). Patient characteristics In the analysis of the unmatched cohorts, RSI patients were younger (62 {IQR 36–92} years vs. 67.7 {IQR 26–87} years, p < 0.001), had a better physical status (ASA score 1 or 2 in 80% vs. 61%, p < 0.001), were less often immunosuppressed (3.4% vs. 7.2%, p = 0.021 and suffered less frequently from coronary heart disease (3.8% vs. 7.2%, p = 0.025). BMI (p = 0.768), previous intraabdominal operation (p = 0.834) and the number of patients with arterial hypertension (p = 0.183) and diabetes (p = 0.052) were comparable. Out of the 585 patients in the unmatched RSI group, 80 (14%) patients had a Type IIa and 505 (86%) had a Type IIIb CDD (Table 3 ). In the unmatched ASI group, out of 318 patients, 79 (25%) patients had a Type IIb and 239 (75%) had a Type IIIc CDD. Patients in the unmatched RSI group experience more relapses prior to surgery compared to the patients in the unmatched ASI group (p < 0.001). Demographic data and symptoms of patients are depicted in Table 3 . After propensity score matching (PSM) controlling for age, BMI, arterial hypertension, coronary heart disease, immunosuppression, and diabetes, 318 RSI patients vs. 318 ASI patients were selected and baseline characteristics were comparable (Table 3 ). In RSI, 38 (12%) patients had a microabscess (Type IIa) and 280 (88%) had recurrent chronic uncomplicated diverticulitis (Type IIIb), while in the ASI group, 79 (25%) had a macroabscess (Type IIb) and 239 (75%) had a chronic complicated diverticulitis (Type IIIc). The number of previous intra-abdominal surgeries remained comparable after PSM, and in addition, the matching did not change the presence and symptomatology of the patients. Patients’ demographics are all reported in Table 3 . Perioperative details Perioperative details of univariate analysis are shown in the Table 4 . After PSM, surgery duration was shorter in the RSI group (211 min. {IQR 60–420} vs. 229 min. {IQR 80–554}, p = 0.003) and the conversion rate was lower (5.0% vs. 13.8%, p < 0.001). Intraoperative complications were comparable between the two groups (3.1% vs. 5.3%, p = 0.238). However, intraoperative bleedings were less prevalent in RSI (2 {0.63%} vs. 10 {3.14%}, p = 0.04). Table 4 – Perioperative details of patients in RSI and the ASI group Unmatched (n = 903) Propensity score matching (PSM) (n = 636) RSI-G n = 585 ASI-G n = 318 p-value RSI-G n = 318 ASI-G n = 318 p-value Surgery time (min, median, IQR) 214 (60–438) 229 (80–554) 0.003 211 (60–420) 229 (80–554) 0.003 Intraoperative complications (N, %) Intestinal lesion Splenic lesion Nerval lesion Diaphragm lesion Bleeding Anaesthetic problems Technical stapler errors 17 (2.9%) 5 (0.85%) 2 (0.34%) 0 1 (0.17%) 6 (1.02%) 0 3 (0.51%) 17 (5.3%) 3 (0.94%) 1 (0.31%) 1 (0.31%) 0 10 (3.14%) 1 (0.31%) 1 (0.31%) 0.7 1 1 0.352 1 0.032 0.352 1 10 (3.1%) 4 (1.26%) 2 (0.63%) 0 0 2 (0.63%) 0 2 (0.63%) 17 (5.3%) 3 (0.94%) 1 (0.31%) 1 (0.31%) 0 10 (3.14%) 1 (0.31%) 1 (0.31%) 0.238 1 1 1 1 0.037 0.352 1 Conversion (N, %) 25 (4.3%) 44 (13.8%) < 0.001 16 (5.0%) 44 (13.8%) < 0.001 Surgical access (N, %) Open Hartmann procedure Laparoscopic Robot-assisted 24 (4%) 0 474 (81%) 87 (15%) 76 (24%) 4 (1%) 209 (66%) 29 (9%) < 0.001 20 (7%) 0 246 (77%) 52 (16%) 76 (24%) 4 (1%) 209 (66%) 29 (9%) < 0.001 Type of anastomosis Hand-sewen Stapler side to end Stapler end to end Stapler side to side No anastomosis 9 (2%) 516 (88%) 29 (5%) 31 (5%) 0 14 (4%) 256 (81%) 22 (7%) 22 (7%) 4 (1%) < 0.001 7 (2%) 272 (86%) 17 (5%) 22 (7%) 0 14 (4%) 256 (81%) 22 (7%) 22 (7%) 4 (1%) 0.114 Methods for specimen removal Mc Burney’s incision Pfannenstiel-Kerr incision Not specified 392 (67%) 136 (23%) 57 (10%) 125 (40%) 65 (20%) 128 (40%) 0.026 209 (66%) 71 (23%) 38 (12%) 125 (40%) 65 (20%) 128 (40%) 0.038 In the RSI group, 77% of the operations were indented to be laparoscopically performed, while in the ASI group only 66% were planned by minimally invasive technique (246 vs. 209, p = 0.002). In addition, 52 patients underwent robot-assisted (DaVinci Xi®) surgery in the RSI group and 29 in the ASI group (16% vs. 9%, p = 0.009). Considering intraoperative conversions from laparoscopic or robotic surgery to open surgery, in ASI 39% of the resections were performed as an open resection whereas 12% of RSI were finished as open surgery (p < 0.001). The technique of anastomosis and operative details are shown in Table 4 . All patients in the RSI group received an anastomosis, while four patients (1%) in the ASI group did not receive an anastomosis rather a Hartmann’s procedure was performed (0/318 vs. 4/318, p = 0.124). Furthermore, only one patient received a planned defunctioning stoma in the RSI group, whereas there were 27 patients who received a planned defunctioning stoma in the ASI group (0.3% vs. 8.5%, p < 0.01) (Table 4 ). Morbidity The median duration of follow-up in the RSI group was 75.5 months (IQR 16–125 months) and in the ASI group 68.4 months (IQR 16–125 months). Overall postoperative complications occurred in 44% of patients in the RSI group, while there were 51% of patients in the ASI group, respectively (p = 0.068). While there was no difference in minor complications (p = 0.689), there were 3.77% and 10% major complications in RSI and ASI, respectively (p = 0.003). For further details of major complications refer to Table 5 . The mean CCI was 9.4 in the RSI group and 12.9 in the ASI group (p = 0.001). There were three anastomotic leaks in RSI group and eight in the ASI group (0.94% vs. 2.52%, p = 0.223). Two patients in the RSI group and seven patients in the ASI group received a revisional stoma due to complication (0.6% vs. 2.2%, p = 0.177). The overall risk for a stoma formation, including the above mentioned planned defunctioning stomas, was significantly lower in the RSI group than in the ASI group, (3 {0.94%} vs. 38 {10.7%}, p < 0.001). In the RSI group, all three stomas were reversed, while in the ASI group 30 of 38 stomas were reversed (3 {100%} vs. 30 {79%}, p = 0.001). The mean number of weeks to stoma reversal was 21 weeks in the RSI group and 19 weeks in the ASI group (p = 0.769). There was no mortality in either group. The univariate analysis is shown in Table 5 . Table 5 – Postoperative complications of patients in the RSI and ASI group Unmatched (n = 903) Propensity score matching (PSM) (n = 636) RSI-G n = 585 ASI-G n = 318 p-value RSI-G n = 318 ASI-G n = 318 p-value Follow-up (months, mean, IQR) 73.8 (16–125) 68.4 (16–125) 0.014 75.5 (16–125) 68.4 (16–125) 0.005 Overall postoperative complication rate (N = patients, %) 253 (43%) 163 (51%) 0.025 139 (44%) 163 (51%) 0.068 Minor complications (N, %) Clavien-Dindo I Clavien-Dindo II Clavien-Dindo IIIa 234 (40%) 79 (14%) 133 (23%) 22 (4%) 139 (44%) 33 (10%) 91 (29%) 15 (5%) 0.29 0.205 0.053 0.487 133 (42%) 45 (14%) 76 (24%) 12 (4%) 139 (44%) 33 (10%) 91 (29%) 15 (5%) 0.689 0.183 0.207 0.695 Major complications, Clavien-Dindo ≥ IIIb (N, %) Clavien-Dindo IIIb Anastomotic leaks Incisional hernias Surgical site infection Bleeding Anastomositis Postoperative acute appendicitis Fistula Stenosis of anastomosis Bowel obstruction Dislocation of Drainage into abdomen Clavien-Dindo IV Anastomotic leaks Allergic reaction Pulmonary embolism Catheter-associated Sepsis Bleeding Clostridium difficile colitis Cardiac event Renal failure Perforation 25 (4.44%) 14 (2.40%) 6 (1.03%) 2 (0.34%) 1 (0.17%) 3 (0.51%) 1 (0.17%) 1 (0.17%) 0 0 0 0 11 (1.88%) 1 (0.17%) 1 (0.17%) 1 (0.17%) 2 (0.34%) 2 (0.34%) 1 (0.17%) 3 (0.51%) 0 0 32 (10%) 20 (6.29%) 5 (1.57%) 9 (2.83%) 0 1 (0.31%) 0 0 2 (0.63%) 1 (0.31%) 1 (0.31%) 1 (0.31%) 12 (3.77%) 2 (0.63%) 0 2 (0.63%) 2 (0.63%) 1 (0.31%) 2 (0.63%) 1 (0.31%) 1 (0.31%) 1 (0.31%) 0.002 0.005 0.119 12 (3.77%) 6 (1.89%) 2 (0.63%) 1 (0.31%) 1 (0.31%) 1 (0.31%) 0 1 (0.31%) 0 0 0 0 6 (1.89%) 1 (0.31%) 1 (0.31%) 0 1 (0.31%) 0 1 (0.31%) 2 (0.63%) 0 0 32 (10%) 20 (6.29%) 5 (1.57%) 9 (2.83%) 0 1 (0.31%) 0 0 2 (0.63%) 1 (0.31%) 1 (0.31%) 1 (0.31%) 12 (3.77%) 2 (0.63%) 0 2 (0.63%) 2 (0.63%) 1 (0.31%) 2 (0.63%) 1 (0.31%) 1 (0.31%) 1 (0.31%) 0.003 0.008 0.231 Mortality (N, %) Anastomotic leaks 1 (0.17%) 1 0 0 1 1 0 0 0 0 1 1 CCI (comprehensive complication index) (mean) 9.3 12.9 < 0.001 9.4 12.9 < 0.001 Anastomotic leaks (N, %) 8 (1.37%) 8 (2.52%) 0.290 3 (0.94%) 8 (2.52%) 0.223 Number of stomas (N, %) Hartmann procedure Planned Revisional 9 (1.54%) 0 1 (0.2%) 8 (1.4%) 38 (10.7%) 4 (1.3%) 27 (8.5%) 7 (2.2%) < 0.001 0.152 < 0.001 0.415 3 (0.94%) 0 1 (0.3%) 2 (0.6%) 38 (10.7%) 4 (1.3%) 27 (8.5%) 7 (2.2%) < 0.001 0.152 < 0.001 0.177 Stoma reversal (N, %) Number of weeks to reversal (weeks, mean, IQR) 8 (88.89%) 21.25 (7–36) 30 (78.95%) 18.83 (2–59) 0.001 0.608 3 (100%) 21 (7–36) 30(78.95%) 18.83 (2–59) 0.001 0.769 Discussion Practical and helpful national and international guidelines on diverticular disease exist. They concur and provide clear recommendations regarding emergency surgery and recommend taking patients-related factors into consideration when surgery is up for debate. There also is consensus on elective surgery in patients with chronic complicated diverticulitis with fistula or stenosis [ 9 , 12 , 13 ]; however, there are some nuances amongst guidelines. The German guidelines recommend considering elective surgery in patients with smoldering diverticulitis (ongoing diverticulitis) after one episode of uncomplicated diverticulitis, and surgery should be offered to patients after conservatively or interventionally treated macroabscess (> 3cm). For patients with recurrent uncomplicated diverticulitis, the quality of life should serve as a decision-making aid for indication for elective surgery [ 9 ]. In contrast, the ESCP (European Society of Coloproctolgy) do not differ between uncomplicated or acute complicated diverticulitis. The goal of the elective surgery is to improve quality of life. The indication is individualized based on frequencies of recurrences, duration and frequencies after attack of diverticulitis and co-morbidities of the patients [ 12 ]. Similarly, the WSES (World Society of Emergency Surgery) also focuses on the patient-related factors, but additionally, recommends planning elective surgery in immunosuppressed patients, which is not recommended in the German guidelines or by the ESCP [ 9 , 12 , 13 ]. Table 2 shows recommendations regarding elective sigmoidectomy in the most common national and international guidelines from the last decade. Nevertheless, in the elective setting the indication for surgery still remains vague. The guidelines are more and more reluctant with an indication for sigmoidectomy in recurrent diverticulitis or after a covered perforation. A recent snap-shot analysis across 49 Swiss hospitals showed that 82% of the sigmoidectomies for diverticular disease were performed for recurrent diverticulitis or after covered perforation [ 18 ]. According to the current version of the German guidelines [ 9 ], there is no indication for elective sigmoidectomy after microabscess (CDD IIa), whereas elective surgery may be offered to patients with a successfully conservatively treated macroabscess (CDD IIb). This is substantiated by the fact that one third of patients after a macroabscess will relapse within one year [ 9 ]. However, a prospective observational trial demonstrated that within two years, 60% of patients with an initial microabscess (IIa) and 100% of patients with macroabscess (IIb) needed a sigmoidectomy due to relapse [ 19 ]. A risk assessment for postoperative complications after elective sigmoidectomy in relation to patient-related factors and severity of disease does not exist. In this study, peri- and postoperative surgical outcomes in two homogenous groups after PSM of patients with different severity of indication requiring elective sigmoidectomy were compared. The study demonstrated that the risk profile in these two groups differ largely. Patients that underwent sigmoidectomy for recurrent diverticulitis or after microabscess (RSI) had an 11-fold decreased risk for the need of a defunctioning stoma, a 3-fold decreased risk for open surgery and a 2.6-fold decreased risk for major morbidity. In chronic complicated diverticulitis (ASI), the proportion of minimally invasive surgery was smaller and the intraoperative conversion rate to open surgery was higher (14% in ASI versus 5% in RSI). Other studies have reported conversion rates of between 2.3% and 23%, but with lack of consistent significant difference between complicated and uncomplicated diverticulitis [ 20 – 22 ]. The operation time was ten minutes longer in the ASI group compared to the RSI group. Although the difference is significant, its clinical relevance is negligible. Mizrahi et al. provided outcomes consistent with our results regarding surgery time, comparing patients with complicated versus uncomplicated diverticulitis (218min. vs. 185min.). However, no open procedures were performed in this study [ 23 ]. Furthermore, Williams et al. investigated surgery duration in elective laparoscopic sigmoidectomy and showed a significant association between operation time and older age, greater BMI, concurrent hypertension and higher ASA classification, as well as the presence of dense adhesions intraoperatively, fistulas and abscesses. However, the data do not support pre-emptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times [ 24 ]. Our study shows similar association due to the presence of more severe diverticular disease with complicated diverticulitis in the ASI group (CDD Type IIb and IIIc). It is quite understandable that with more severe courses of disease, more difficult intraoperative situations are entailed. Nevertheless, our data also supports the laparoscopic approach if progress is safely being made, especially since intraoperative anesthesiological problems or complications are rare (0.3% in the ASI group). In the two groups, a comparably low incidence of intraoperative complications was observed (3% vs. 5% in RSI vs ASI, respectively), the most frequent being intraoperative bleeding in different locations (0.6% vs. 3.1% in RSI vs ASI, respectively). This might also be due to difficult scarring conditions in more severe disease courses in the ASI group. Other intraoperative complications were comparable to those reported in other studies for elective sigmoidectomy for diverticular disease [ 22 , 25 , 26 ]. This study showed an overall complications rate of 44% in the RSI group and 51% in the ASI group (p = 0.068). Similar rates were found in minor complications (Clavien-Dindo < IIIb) with 42% in the RSI group and 44% in the ASI group (p = 0.689). Important to note, the analysis on postoperative complications in this study was performed very accurate and any documented deviation from normal course has been included in this study for analysis, and most of the complications were Clavien-Dindo I and II (38% in RSI vs. 39% in ASI). Therefore, in our point of view, this is the reason why the complications rate in this study is higher when compared to other studies [ 10 , 11 , 20 , 21 , 23 , 25 – 27 ]. RSI patients showed a lower CCI compared with patients in the ASI group (9.4 vs. 12.9). Further data regarding the CCI in patients following elective sigmoidectomy for diverticulitis are currently non-existent. Intriguingly, the results of postoperative major complications showed a difference between the analysed groups. In the RSI group, postoperative major complication occurred in 3.8% while 10% occurred in the ASI group. Most of the surgery-related complications were anastomotic leaks and incisional hernias. Mizrahi et al. provided a major complication rate of 1% in patients with uncomplicated diverticulitis and 3% in patients with complicated diverticulitis. However, it should be noted again that open surgery had been excluded [ 23 ]. Furthermore, the largest case series by Jones et al. that included 500 laparoscopic resections, showed a postoperative major complication rate similar to this study of 11.5% in patients with complicated diverticulitis and 10.9% in patient with uncomplicated diverticulitis respectively, but without a statistically significant difference [ 20 ]. On the other hand, Martel et al. reported that patients with severe disease experienced a significantly higher rate of surgical complications and general medical complications [ 22 ]. In the present study, 10.7% of ASI patients and 0.9% of RSI patients left the hospital with a stoma. In accordance with these findings, Martel et al. recorded a higher rate of defunctioning ileostomy in complicated versus uncomplicated disease (4.2% vs. 21%, respectively, p < 0.05) [ 22 ]. Even higher rates of ileostomy creation were reported by Royds et al. (5.2% vs. 35%, p < 0.05) [ 21 ]. These results show an association with the progression of the disease and creation of ileostomy. Although creation of ileostomy is not considered a complication, it carries a considerable burden for the patients and may imply potential future complications to the stoma itself or to future surgery. The retrospective design is accompanied with an inherent risk of selection bias. Neither the follow-up, nor the hospital stay and quality of life were included in the data collected. One strength is the analysis, including most influential co-morbidities and the meticulous collection of data performed with the four-eyes principle. However, history of tobacco smoking, which is also known as a risk factor for complicated diverticulitis, was not recorded. Elective sigmoidectomy were performed or assisted by six highly experienced colorectal surgeons. Although institutional standard operating procedures (SOP) were strictly followed, potential operator bias due to possible differences between surgeons for treatment and surgical technique may exist. When performing adequate benefit-risk assessment with every individual patient, it is of utmost importance to inquire about quality of life. Several studies investigating quality of life in patients with recurring or ongoing diverticulitis lend themselves to support the benefits of surgery. The DIRECT trial resulted in a significantly increase quality of life at five-year follow-up compared with conservative management and therefore supports surgery despite inherent risk of complications of operative management [ 10 ]. Furthermore, the LASER trial comparing laparoscopic elective sigmoid resection with conservative treatment in a randomized setting showed a significant improvement of quality of life after surgery with a 10% risk of major complications [ 11 ]. Conclusion The current study demonstrates that the surgical risk in terms of major complications, complications burden (CCI), risk of receiving a defunctioning stoma and the risk for the need of open surgery is distinctly different between recurring uncomplicated diverticulitis or after microabscess compared to more advanced disease stages such as after a macroabscess or in case of chronic complicated diverticulitis. The findings of this study will allow more tailored counseling when it comes to the shared decision making between patient and surgeon for or against elective sigmoidectomy. Declarations Competing interests : The authors declare that they have no conflicts of interest. Funding : The study was founded by institutional means. Author contributions : Fabio Nocera and Fabian Haak wrote the main manuscript text, created tables and figures and collected most of the data. Alberto Posabella helped keep data files updated, performed limited data analysis and reviewed the manuscript. Most of the reviewing, coordination, rewriting and data analyses was completed by Fiorenzo Angehrn, Ralph Peterli and Daniel Steinemann. Beat Müller and Daniel Steinemann were responsible for the study design and coordination as well as for reviewing the manuscript. Acknowledgement : The illustrations were created by Lisa Cuthbertson. References Köhler L, Sauerland S, Neugebauer E (1999) Diagnosis and treatment of diverticular disease: Results of a consensus development conference. Surg Endosc 13:430–436. https://doi.org/10.1007/s004649901007 Ambrosetti P, Robert JH, Witzig JA, et al (1994) Acute left colonic diverticulitis in young patients. J Am Coll Surg 179:156–160 Rose J, Parina RP, Faiz O, et al (2015) Long-term outcomes after initial presentation of diverticulitis. Ann Surg 262:1046–1053. https://doi.org/10.1097/SLA.0000000000001114 Ritz J-P, Lehmann KS, Frericks B, et al (2011) Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 149:606–613. https://doi.org/10.1016/j.surg.2010.10.005 Boermeester MA, Humes DJ, Velmahos GC, Søreide K (2016) Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis. World J Surg 40:2537–2545. https://doi.org/10.1007/s00268-016-3560-8 Pittet O, Kotzampassakis N, Schmidt S, et al (2009) Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis? World J Surg 33:547–552. https://doi.org/10.1007/s00268-008-9898-9 Leifeld L, Germer CT, Böhm S, et al (2014) [S2k guidelines diverticular disease/diverticulitis]. Z Gastroenterol 52:663–710. https://doi.org/10.1055/s-0034-1366692 Horesh N, Wasserberg N, Zbar AP, et al (2016) Changing paradigms in the management of diverticulitis. Int J Surg 33 Pt A:146–150. https://doi.org/10.1016/j.ijsu.2016.07.072 Leifeld L, Germer CT, Böhm S, et al (2022) S3-Leitlinie Divertikelkrankheit/Divertikulitis-Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs-und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein-und Viszeralchirurgie (DGAV). Z Gastroenterol 60:613–688. https://doi.org/10.1055/a-1741-5724 van de Wall BJM, Stam MAW, Draaisma WA, et al (2017) Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2:13–22. https://doi.org/10.1016/S2468-1253(16)30109-1 Santos A, Mentula P, Pinta T, et al (2021) Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized Clinical Trial. JAMA Surg 156:129–136. https://doi.org/10.1001/jamasurg.2020.5151 Schultz JK, Azhar N, Binda GA, et al (2020) European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Disease 22:5–28. https://doi.org/10.1111/codi.15140 Sartelli M et al. (2020) 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergeny setting. World J Emerg Surg. https://doi.org/https://doi.org/10.1186/s13017-020-00313-4 Galetin T, Galetin A, Vestweber K-H, Rink AD (2018) Systematic review and comparison of national and international guidelines on diverticular disease. Int J Colorectal Dis 33:261–272. https://doi.org/10.1007/s00384-017-2960-z Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae Slankamenac K, Graf R, Barkun J, et al (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7. https://doi.org/10.1097/SLA.0b013e318296c732 R Core Team (2021) A language and environment for statistical computing Faes S, Hübner M, Demartines N, et al (2021) Elective Surgery for Diverticulitis in Swiss Hospitals. Front Surg 8:717228. https://doi.org/10.3389/fsurg.2021.717228 Lauscher JC, Lock JF, Aschenbrenner K, et al (2021) Validation of the German Classification of Diverticular Disease (VADIS)-a prospective bicentric observational study. Int J Colorectal Dis 36:103–115. https://doi.org/10.1007/s00384-020-03721-9 Jones OM, Stevenson ARL, Clark D, et al (2008) Laparoscopic resection for diverticular disease: follow-up of 500 consecutive patients. Ann Surg 248:1092–1097. https://doi.org/10.1097/SLA.0b013e3181884923 Royds J, O’Riordan JM, Eguare E, et al (2012) Laparoscopic surgery for complicated diverticular disease: a single-centre experience. Colorectal Dis 14:1248–1254. https://doi.org/10.1111/j.1463-1318.2011.02924.x Martel G, Bouchard A, Soto CM, et al (2010) Laparoscopic colectomy for complex diverticular disease: a justifiable choice? Surg Endosc 24:2273–2280. https://doi.org/10.1007/s00464-010-0951-z Mizrahi I, Abu-Gazala M, Fernandez LM, et al (2021) Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease. Colorectal Dis 23:2948–2954. https://doi.org/10.1111/codi.15837 Williams J, Stocchi L, Aiello A, et al (2021) No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease. Surg Endosc 35:2823–2830. https://doi.org/10.1007/s00464-020-07717-y Raskin ER, Keller DS, Gorrepati ML, et al (2019) Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease. JSLS 23:. https://doi.org/10.4293/JSLS.2018.00073 Bouillot JL, Berthou JC, Champault G, et al (2002) Elective laparoscopic colonic resection for diverticular disease: results of a multicenter study in 179 patients. Surg Endosc 16:1320–1323. https://doi.org/10.1007/s00464-001-9236-x Ilyas MIM, Zangbar B, Nfonsam VN, et al (2017) Are there differences in outcome after elective sigmoidectomy for diverticular disease and for cancer? A national inpatient study. Colorectal Dis 19:260–265. https://doi.org/10.1111/codi.13461 Sartelli M, Viale P, Catena F, et al (2013) 2013 WSES guidelines for management of intra-abdominal infections. World Journal of Emergency Surgery 8:1–29. https://doi.org/10.1186/1749-7922-8-3 Sartelli M, Catena F, Ansaloni L, et al (2016) WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 11:37. https://doi.org/10.1186/s13017-016-0095-0 Andeweg CS, Mulder IM, Felt-Bersma RJF, et al (2013) Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 30:278–292. https://doi.org/10.1159/000354035 Binda GA, Cuomo R, Laghi A, et al (2015) Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 19:615–626. https://doi.org/10.1007/s10151-015-1370-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Aug, 2023 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Major revision 17 Jun, 2023 Reviews received at journal 22 May, 2023 Reviewers agreed at journal 19 May, 2023 Reviewers invited by journal 19 May, 2023 Editor assigned by journal 18 May, 2023 Submission checks completed at journal 17 May, 2023 First submitted to journal 15 May, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2939249","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":201490746,"identity":"c16ed324-374c-471e-a240-4c7dc582c250","order_by":0,"name":"Fabio Nocera","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Nocera","suffix":""},{"id":201490747,"identity":"ed91aa7e-bb99-466f-9003-8125bd0ce02b","order_by":1,"name":"Fabian Haak","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"","lastName":"Haak","suffix":""},{"id":201490748,"identity":"9514735d-11f8-4d13-bd2e-153e57e3a734","order_by":2,"name":"Alberto Posabella","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Posabella","suffix":""},{"id":201490749,"identity":"d1594f82-0699-4bac-a418-620b06e9a65b","order_by":3,"name":"Fiorenzo Valente Angehrn","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fiorenzo","middleName":"Valente","lastName":"Angehrn","suffix":""},{"id":201490750,"identity":"aa31abe5-7c73-40e7-b623-74eb98839722","order_by":4,"name":"Ralph Peterli","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ralph","middleName":"","lastName":"Peterli","suffix":""},{"id":201490751,"identity":"963eacad-3bfb-4b47-8b70-3a74b8cbe658","order_by":5,"name":"Beat Peter Müller","email":"","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Beat","middleName":"Peter","lastName":"Müller","suffix":""},{"id":201490752,"identity":"1c6731b1-943e-456c-af84-4d4d6d1e12aa","order_by":6,"name":"Daniel C. Steinemann","email":"data:image/png;base64,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","orcid":"","institution":"University Center for Gastrointestinal and Liver Disease -Clarunis St. Clara Hospital and University Hospital Basel","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"C.","lastName":"Steinemann","suffix":""}],"badges":[],"createdAt":"2023-05-15 19:59:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2939249/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2939249/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-023-03034-9","type":"published","date":"2023-08-03T21:50:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":37247601,"identity":"bb7bae38-ded2-491f-9e22-9394073f8be0","added_by":"auto","created_at":"2023-05-19 15:08:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3139676,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of diverticulitis types evaluated in this study based on CDD (A= Acute uncomplicated sigmoid diverticulitis, B= Sigmoid diverticulitis with microabscess= Sigmoid diverticulitis with macroabscess, D= Complicated sigmoid diverticulitis with stenosis and fistulas)\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2939249/v1/4d067687fd81cb0482b184ab.jpg"},{"id":37247600,"identity":"b0b377e4-0cc6-4ec0-94a5-ce6b0720bd13","added_by":"auto","created_at":"2023-05-19 15:08:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76913,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of patient allocation and assignment (PSM= propensity score matching, RSI= relative surgery indication, ASI= absolute surgery indication, U = unmatched)\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2939249/v1/4cac6455a8ebf7f09e09023b.jpg"},{"id":44735479,"identity":"d8f434cb-480f-4ad3-83c5-62aeda4f6ad7","added_by":"auto","created_at":"2023-10-16 22:25:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":711858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2939249/v1/0a22b4d8-b553-4d02-96a2-86b8db197c9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the past, the indication for elective sigmoidectomy after complicated or recurrent diverticulitis was justified by the expected risk of free perforation during recurrence [1, 2]. Based on more recent studies however, it is known today that the risk of perforation is highest at the first episode (5-25%) and decreases with the number of further attacks to less than 1% by the 5\u003csup\u003eth\u003c/sup\u003e episode [3\u0026ndash;5]. In addition, it has been found that recurrent episodes of diverticulitis neither lead to a higher complication rate nor to a higher failure rate of conservative therapy [6]. \u0026nbsp;Based on these findings, the understanding of this disease has changed and the previously propagated recommendation for resection after the second inflammatory episode must therefore be considered obsolete [7\u0026ndash;9]. Today, the indication for elective sigmoidectomy in diverticulitis must respect individual patient-related factors such as comorbidities and the impact on quality of life. This is highlighted in particular by two recent published studies: \u0026nbsp;The multicenter DIRECT trial such as the LASER trial demonstrated both in a randomized setting better results in quality of life comparing laparoscopic elective sigmoid resection with conservative treatment in patients with recurrent and persisting abdominal complaints. Both support surgery despite inherent risk of complications of operative management [10, 11].\u003c/p\u003e\n\u003cp\u003eClinical guidelines for diverticulitis aim to use diagnostic methods and therapeutic strategies in a reasonable way, avoiding under- or overtreatment. \u0026nbsp;Common across all guidelines is the assessment of the risk versus the benefit of the surgery and accordingly either recommend an operation or not [9, 12, 13]. However, none of these guidelines stratify the actual risk of surgery according to the classification of the diverticular disease or the severity of the disease. In addition, which specific groups of patients would benefit from elective surgery or at what time these patients should be operated on are questions that continue to be debated due to a lack of evidence-based data [14]. This may lead to different or misleading decision-making for elective surgery in the individual situation.\u003c/p\u003e\n\u003cp\u003eFor these reasons, the aim of this study is to evaluate the surgical outcomes according to the different severities of indications, which considers the risk of the intervention, i.e., the morbidity of the surgery and the severity stadium of the disease. The evaluation of these different severities of indications enables us to stratify the specific risk of each classification grade and/or indication severity and helps us to achieve a more patient-related assessment, allowing us to perform better benefit-risk counseling.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e All patients who underwent elective sigmoid resection for diverticulitis, as defined according to clinical and radiological diagnosis, between January 2011 and March 2020 at the University Center for Gastrointestinal and Liver Disease Clarunis (Basel, Switzerland) were included in this study.\u003c/p\u003e \u003cp\u003eThe preferred approach in all patients was laparoscopic surgeries if not contraindicated. Sigmoidectomy was performed using a central dissection with resection of the inferior mesenteric artery or by peripheral dissection according to surgeon\u0026rsquo;s preference.\u003c/p\u003e \u003cp\u003eThe patients were divided into two groups based on the severity of the surgical indication. The severity has been evaluated by the German guidelines and the German classification system CDD (classification of diverticular disease) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Elective sigmoidectomy has a strong indication in patients with stenosis or fistula (CDD Type IIIc) and should be offered in patients with conservatively/interventional treated macroabscess (CDD Type IIb) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The less strict indication in contrast, considers patients with \u0026ldquo;milder\u0026rdquo; complaints, such as patients with recurrent uncomplicated diverticulitis (CDD Type IIIb) and patients with conservatively treated microabscess (CDD Type IIa) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Due to these indications, patients were divided into a relative surgery indication group (RSI) and an absolute surgery indication group (ASI). RSI included recurrent uncomplicated diverticulitis (CDD IIIb) and surgery after complicated acute diverticulitis with a microabscess (CDD IIa). ASI included surgery after complicated acute diverticulitis with a macroabscess (CDD IIb) and patients with a complicated chronic diverticulitis with stenosis or fistula (CDD IIIc).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Classification of diverticular disease (CDD) according to the German S2k guideline [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSynonym\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCDD Type\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymptomatic diverticulosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIdentification of diverticula in colon\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAcute uncomplicated diverticulitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiverticulitis without perforation*\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiverticulitis with phlegmonous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIa\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiverticulitis with phlegmonous peridiverticulitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAcute complicated diverticulitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiverticulitis with covered perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMicroabscess (\u0026lt;\u0026thinsp;1cm), minimal free paracolic air\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIa\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMacroabscess (\u0026gt;\u0026thinsp;1cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFree perforated diverticulitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePurulent peritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIc*\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFecal peritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIc*\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eChronic diverticular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSymptomatic uncomplicated diverticular disease (SUDD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTypical clinical features*\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIa\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelapsing diverticulitis without complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrent signs of inflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelapsing diverticulitis with complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIdentifications of stenoses, fistulas, conglomerate tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIc\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiverticular bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIdentification of source of bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Exclusion criteria were emergency surgeries. The Ethical Committee of Northwestern Switzerland approved the study, and all eligible patients provided general informed consent (EKNZ Nr. 2018\u0026thinsp;\u0026minus;\u0026thinsp;00318).\u003c/p\u003e\u003cp\u003eTable 2 \u0026ndash; Recommendation regarding elective sigmoidectomy by different national and international guidelines [9, 12, 13, 28\u0026ndash;31]\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" style=\"width: 708px; height: 643.87px;\" width=\"708\" height=\"643.87\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 1: ● = recommended, ○ = not recommended, * = to consider, - = not discussed, 1=pelvic abscess treated by means of percutaneous drainage due to the poor long-term outcomes of conservative treatment, 2 = in specific clinical situations (persisting symptoms and signs, degree of diverticulitis)\u003c/p\u003e\n\u003cp\u003eDGVS/DGAV: German Society for Gastroenterology, Digestive and Metabolic Diseases/German Society for General and Visceral Surgery\u003c/p\u003e\n\u003cp\u003eWSES: World Society of Emergency Surgery\u003c/p\u003e\n\u003cp\u003eESCP: European Society of Coloproctology\u003c/p\u003e\n\u003cp\u003eSICCR: Italian Society of Colorectal Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNSS: Netherlands Society of Surgeons\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData from enrolled patients were included prospectively in an institutional study register database. Records were analysed retrospectively for demographic data such as age, gender, body mass index (BMI), American Society of Anaesthesiology (ASA) classification, previous intraabdominal surgeries, classification of diverticular disease (CCD), recurrent diverticulitis, number of recurrences, preoperative colonoscopy, preoperative symptoms and co-morbidities (arterial hypertension, coronary artery disease, immunosuppression and diabetes mellitus), surgical data such as surgery time (skin incision to wound closure), intraoperative complications, conversion rate to open surgery, type of access, type of anastomosis and specimen extraction technique, postoperative data such as overall morbidity according to Clavien-Dindo [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], minor morbidity (Clavien-Dindo\u0026thinsp;\u0026lt;\u0026thinsp;IIIb), major morbidity (Clavien-Dindo \u0026ge;IIIb), anastomotic leaks, mortality, comprehensive complications index (CCI) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], number of defunctioning stomas (Hartmann procedure, planned and unplanned) and number of stoma reversals. Complications were defined as any type of deviation during surgical procedure or postoperative course. In order not to miss a recording of any complication, the recording of the complications was carried out in duplicate form in which the resident physician records the complication, and the head surgeon supervises and confirms or corrects the recording. Anastomotic leaks were diagnosed by computer tomography and/or endoscopy in cases of clinical suspicion, depending on the surgeon\u0026rsquo;s preference. A patient could suffer from more than one complication, and thus, their total number could be higher than the number of patients with complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eStatistics analysis\u003c/h2\u003e \u003cp\u003eContinuous data were summarized by using mean and standard deviation (SD) for normally distributed data, or medians and interquartile range for non-normally distributed data. Student\u0026rsquo;s t-test or Mann-Witney were used to compare differences, as appropriate. Categorical variables were summarized using counts and/or percentages and were analysed with Fisher\u0026rsquo;s exact test or Pearson\u0026rsquo;s Chi-squared test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eTo control for potential confounders, a propensity score was generated for each patient from a multivariable logistic regression model based on key co-variables (age, BMI, arterial hypertension, coronary heart disease, immunosuppression and diabetes) as independent variables with relative or absolute indication for elective surgery as a binary dependent variable. Those baseline variables in the univariate analysis with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 or otherwise of specific clinical interest were added to the model. Each patient with relative indication was matched with replacement to one patient with absolute indication in a 1:1 ratio, with a caliper width of 0.20 standard deviation of the logit of the propensity score using R statistical software version 2.13.1 using package \u0026ldquo;MatchIt\u0026rdquo; [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The quality of the match was assessed by comparing the patient characteristics before and after matching as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Data in the matched data set were analysed using a generalised random block design for continuous variables and conditional logistic regression for categorical variables.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Demographic data of patients in the RSI and ASI group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnmatched\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;903)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePropensity score matching (PSM)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;636)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (36\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.7 (26\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.6 (43\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.7 (26\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e233 (39%)\u003c/p\u003e \u003cp\u003e352 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (38%)\u003c/p\u003e \u003cp\u003e196 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e108 (34%)\u003c/p\u003e \u003cp\u003e210 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e122 (38%)\u003c/p\u003e \u003cp\u003e196 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody mass index\u003c/b\u003e kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.6 (14.8\u0026ndash;45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.6 (16-48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.4 (14.8\u0026ndash;45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.6 (16-48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA-Score\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (80%)\u003c/p\u003e \u003cp\u003e28 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (61%)\u003c/p\u003e \u003cp\u003e40 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52 (83%)\u003c/p\u003e \u003cp\u003e18 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63 (61%)\u003c/p\u003e \u003cp\u003e40 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious intra-abdominal surgery\u003c/b\u003e (N patients, % of patients)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e316 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e181 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e169 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.381\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClassification of diverticular disease (CDD)\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eIIa\u003c/p\u003e \u003cp\u003eIIb\u003c/p\u003e \u003cp\u003eIIIb\u003c/p\u003e \u003cp\u003eIIIc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (14%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e505 (86%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e79 (25%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e239 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (12%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e280 (88%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e79 (25%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e239 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrent diverticulitis\u003c/b\u003e (N patients, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e544 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e298 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e224 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of recurrences\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (8%)\u003c/p\u003e \u003cp\u003e188 (45%)\u003c/p\u003e \u003cp\u003e181 (43%)\u003c/p\u003e \u003cp\u003e16 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (37%)\u003c/p\u003e \u003cp\u003e50 (45%)\u003c/p\u003e \u003cp\u003e20 (18%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.915\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (7%)\u003c/p\u003e \u003cp\u003e99 (45%)\u003c/p\u003e \u003cp\u003e98 (44%)\u003c/p\u003e \u003cp\u003e8 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40 (37%)\u003c/p\u003e \u003cp\u003e50 (45%)\u003c/p\u003e \u003cp\u003e20 (18%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e1.0\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative coloscopy\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eNormal\u003c/p\u003e \u003cp\u003eInflammation\u003c/p\u003e \u003cp\u003eChronic-sclerosing\u003c/p\u003e \u003cp\u003eFixed loop/Kinking\u003c/p\u003e \u003cp\u003eStenosis\u003c/p\u003e \u003cp\u003eFistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e390 (67%)\u003c/p\u003e \u003cp\u003e339 (86%)\u003c/p\u003e \u003cp\u003e13 (4%)\u003c/p\u003e \u003cp\u003e23 (6%)\u003c/p\u003e \u003cp\u003e15 (4%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e206 (65%)\u003c/p\u003e \u003cp\u003e42 (20%)\u003c/p\u003e \u003cp\u003e10 (5%)\u003c/p\u003e \u003cp\u003e33 (16%)\u003c/p\u003e \u003cp\u003e21 (10%)\u003c/p\u003e \u003cp\u003e97 (47%)\u003c/p\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.376\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.004\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e212 (67%)\u003c/p\u003e \u003cp\u003e182 (86%)\u003c/p\u003e \u003cp\u003e7 (3%)\u003c/p\u003e \u003cp\u003e14 (7%)\u003c/p\u003e \u003cp\u003e9 (4%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e206 (65%)\u003c/p\u003e \u003cp\u003e42 (20%)\u003c/p\u003e \u003cp\u003e10 (5%)\u003c/p\u003e \u003cp\u003e33 (16%)\u003c/p\u003e \u003cp\u003e21 (10%)\u003c/p\u003e \u003cp\u003e97 (47%)\u003c/p\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.466\u003c/p\u003e \u003cp\u003e0.006\u003c/p\u003e \u003cp\u003e0.038\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative symptoms\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003ePain\u003c/p\u003e \u003cp\u003eFever\u003c/p\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003cp\u003eStool irregularities\u003c/p\u003e \u003cp\u003eHaematochezia\u003c/p\u003e \u003cp\u003eNausea\u003c/p\u003e \u003cp\u003eUrogynaecology symptoms\u003c/p\u003e \u003cp\u003eGeneral condition deterioration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e273 (46%)\u003c/p\u003e \u003cp\u003e20 (3%)\u003c/p\u003e \u003cp\u003e46 (8%)\u003c/p\u003e \u003cp\u003e28 (5%)\u003c/p\u003e \u003cp\u003e46 (8%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e11 (2%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e15 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e160 (50%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003cp\u003e61 (19%)\u003c/p\u003e \u003cp\u003e36 (11%)\u003c/p\u003e \u003cp\u003e51 (16%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003cp\u003e31 (10%)\u003c/p\u003e \u003cp\u003e26 (8%)\u003c/p\u003e \u003cp\u003e19 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.297\u003c/p\u003e \u003cp\u003e0.851\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.292\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e153 (48%)\u003c/p\u003e \u003cp\u003e11 (3%)\u003c/p\u003e \u003cp\u003e25 (8%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003cp\u003e26 (8%)\u003c/p\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003cp\u003e7 (2%)\u003c/p\u003e \u003cp\u003e1 (0%)\u003c/p\u003e \u003cp\u003e10 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e160 (50%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003cp\u003e61 (19%)\u003c/p\u003e \u003cp\u003e36 (11%)\u003c/p\u003e \u003cp\u003e51 (16%)\u003c/p\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003cp\u003e31 (10%)\u003c/p\u003e \u003cp\u003e26 (8%)\u003c/p\u003e \u003cp\u003e19 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.634\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.003\u003c/p\u003e \u003cp\u003e0.725\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCo-morbidities\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eArterial Hypertension\u003c/p\u003e \u003cp\u003eCoronary heart disease\u003c/p\u003e \u003cp\u003eImmunosuppression\u003c/p\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e185 (32%)\u003c/p\u003e \u003cp\u003e22 (4%)\u003c/p\u003e \u003cp\u003e20 (3%)\u003c/p\u003e \u003cp\u003e27 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (36%)\u003c/p\u003e \u003cp\u003e23 (7%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e25 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003cp\u003e0.025\u003c/p\u003e \u003cp\u003e0.021\u003c/p\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114 (36%)\u003c/p\u003e \u003cp\u003e19 (6%)\u003c/p\u003e \u003cp\u003e18 (6%)\u003c/p\u003e \u003cp\u003e17 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e115 (36%)\u003c/p\u003e \u003cp\u003e23 (7%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e25 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.632\u003c/p\u003e \u003cp\u003e0.625\u003c/p\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the study period, a total of 998 operations for diverticular disease were performed at the University Center for Gastrointestinal and Liver Disease Clarunis (Basel, Switzerland). 95 patients were excluded due to exclusion criteria. The remaining 903 patients were analysed in context of this study. In the univariate analysis, 585 patients were assigned to the RSI group and 318 patients to the ASI group. After propensity score-matching (PSM) was applied, 636 remained for analysis, 318 patients for each group (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eIn the analysis of the unmatched cohorts, RSI patients were younger (62 {IQR 36\u0026ndash;92} years vs. 67.7 {IQR 26\u0026ndash;87} years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), had a better physical status (ASA score 1 or 2 in 80% vs. 61%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), were less often immunosuppressed (3.4% vs. 7.2%, p\u0026thinsp;=\u0026thinsp;0.021 and suffered less frequently from coronary heart disease (3.8% vs. 7.2%, p\u0026thinsp;=\u0026thinsp;0.025). BMI (p\u0026thinsp;=\u0026thinsp;0.768), previous intraabdominal operation (p\u0026thinsp;=\u0026thinsp;0.834) and the number of patients with arterial hypertension (p\u0026thinsp;=\u0026thinsp;0.183) and diabetes (p\u0026thinsp;=\u0026thinsp;0.052) were comparable. Out of the 585 patients in the unmatched RSI group, 80 (14%) patients had a Type IIa and 505 (86%) had a Type IIIb CDD (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the unmatched ASI group, out of 318 patients, 79 (25%) patients had a Type IIb and 239 (75%) had a Type IIIc CDD. Patients in the unmatched RSI group experience more relapses prior to surgery compared to the patients in the unmatched ASI group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Demographic data and symptoms of patients are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAfter propensity score matching (PSM) controlling for age, BMI, arterial hypertension, coronary heart disease, immunosuppression, and diabetes, 318 RSI patients vs. 318 ASI patients were selected and baseline characteristics were comparable (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In RSI, 38 (12%) patients had a microabscess (Type IIa) and 280 (88%) had recurrent chronic uncomplicated diverticulitis (Type IIIb), while in the ASI group, 79 (25%) had a macroabscess (Type IIb) and 239 (75%) had a chronic complicated diverticulitis (Type IIIc). The number of previous intra-abdominal surgeries remained comparable after PSM, and in addition, the matching did not change the presence and symptomatology of the patients. Patients\u0026rsquo; demographics are all reported in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003ePerioperative details\u003c/h2\u003e \u003cp\u003ePerioperative details of univariate analysis are shown in the Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e. After PSM, surgery duration was shorter in the RSI group (211 min. {IQR 60\u0026ndash;420} vs. 229 min. {IQR 80\u0026ndash;554}, p\u0026thinsp;=\u0026thinsp;0.003) and the conversion rate was lower (5.0% vs. 13.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Intraoperative complications were comparable between the two groups (3.1% vs. 5.3%, p\u0026thinsp;=\u0026thinsp;0.238). However, intraoperative bleedings were less prevalent in RSI (2 {0.63%} vs. 10 {3.14%}, p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Perioperative details of patients in RSI and the ASI group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnmatched\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;903)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePropensity score matching (PSM)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;636)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time\u003c/b\u003e (min, median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e214 (60\u0026ndash;438)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e229 (80\u0026ndash;554)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e211 (60\u0026ndash;420)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e229 (80\u0026ndash;554)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative complications (N, %)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIntestinal lesion\u003c/p\u003e \u003cp\u003eSplenic lesion\u003c/p\u003e \u003cp\u003eNerval lesion\u003c/p\u003e \u003cp\u003eDiaphragm lesion\u003c/p\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003cp\u003eAnaesthetic problems\u003c/p\u003e \u003cp\u003eTechnical stapler errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (2.9%)\u003c/p\u003e \u003cp\u003e5 (0.85%)\u003c/p\u003e \u003cp\u003e2 (0.34%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e6 (1.02%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e3 (0.51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (5.3%)\u003c/p\u003e \u003cp\u003e3 (0.94%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e10 (3.14%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.352\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.032\u003c/p\u003e \u003cp\u003e0.352\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (3.1%)\u003c/p\u003e \u003cp\u003e4 (1.26%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (5.3%)\u003c/p\u003e \u003cp\u003e3 (0.94%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e10 (3.14%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e0.037\u003c/p\u003e \u003cp\u003e0.352\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConversion (N, %)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical access (N, %)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOpen\u003c/p\u003e \u003cp\u003eHartmann procedure\u003c/p\u003e \u003cp\u003eLaparoscopic\u003c/p\u003e \u003cp\u003eRobot-assisted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (4%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e474 (81%)\u003c/p\u003e \u003cp\u003e87 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (24%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e209 (66%)\u003c/p\u003e \u003cp\u003e29 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (7%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e246 (77%)\u003c/p\u003e \u003cp\u003e52 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76 (24%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003cp\u003e209 (66%)\u003c/p\u003e \u003cp\u003e29 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of anastomosis\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHand-sewen\u003c/p\u003e \u003cp\u003eStapler side to end\u003c/p\u003e \u003cp\u003eStapler end to end\u003c/p\u003e \u003cp\u003eStapler side to side\u003c/p\u003e \u003cp\u003eNo anastomosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (2%)\u003c/p\u003e \u003cp\u003e516 (88%)\u003c/p\u003e \u003cp\u003e29 (5%)\u003c/p\u003e \u003cp\u003e31 (5%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (4%)\u003c/p\u003e \u003cp\u003e256 (81%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (2%)\u003c/p\u003e \u003cp\u003e272 (86%)\u003c/p\u003e \u003cp\u003e17 (5%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (4%)\u003c/p\u003e \u003cp\u003e256 (81%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e22 (7%)\u003c/p\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethods for specimen removal\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMc Burney\u0026rsquo;s incision\u003c/p\u003e \u003cp\u003ePfannenstiel-Kerr incision\u003c/p\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392 (67%)\u003c/p\u003e \u003cp\u003e136 (23%)\u003c/p\u003e \u003cp\u003e57 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (40%)\u003c/p\u003e \u003cp\u003e65 (20%)\u003c/p\u003e \u003cp\u003e128 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e209 (66%)\u003c/p\u003e \u003cp\u003e71 (23%)\u003c/p\u003e \u003cp\u003e38 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e125 (40%)\u003c/p\u003e \u003cp\u003e65 (20%)\u003c/p\u003e \u003cp\u003e128 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the RSI group, 77% of the operations were indented to be laparoscopically performed, while in the ASI group only 66% were planned by minimally invasive technique (246 vs. 209, p\u0026thinsp;=\u0026thinsp;0.002). In addition, 52 patients underwent robot-assisted (DaVinci Xi\u0026reg;) surgery in the RSI group and 29 in the ASI group (16% vs. 9%, p\u0026thinsp;=\u0026thinsp;0.009). Considering intraoperative conversions from laparoscopic or robotic surgery to open surgery, in ASI 39% of the resections were performed as an open resection whereas 12% of RSI were finished as open surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe technique of anastomosis and operative details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e. All patients in the RSI group received an anastomosis, while four patients (1%) in the ASI group did not receive an anastomosis rather a Hartmann\u0026rsquo;s procedure was performed (0/318 vs. 4/318, p\u0026thinsp;=\u0026thinsp;0.124). Furthermore, only one patient received a planned defunctioning stoma in the RSI group, whereas there were 27 patients who received a planned defunctioning stoma in the ASI group (0.3% vs. 8.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eMorbidity\u003c/h2\u003e \u003cp\u003eThe median duration of follow-up in the RSI group was 75.5 months (IQR 16\u0026ndash;125 months) and in the ASI group 68.4 months (IQR 16\u0026ndash;125 months). Overall postoperative complications occurred in 44% of patients in the RSI group, while there were 51% of patients in the ASI group, respectively (p\u0026thinsp;=\u0026thinsp;0.068). While there was no difference in minor complications (p\u0026thinsp;=\u0026thinsp;0.689), there were 3.77% and 10% major complications in RSI and ASI, respectively (p\u0026thinsp;=\u0026thinsp;0.003). For further details of major complications refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The mean CCI was 9.4 in the RSI group and 12.9 in the ASI group (p\u0026thinsp;=\u0026thinsp;0.001). There were three anastomotic leaks in RSI group and eight in the ASI group (0.94% vs. 2.52%, p\u0026thinsp;=\u0026thinsp;0.223). Two patients in the RSI group and seven patients in the ASI group received a revisional stoma due to complication (0.6% vs. 2.2%, p\u0026thinsp;=\u0026thinsp;0.177). The overall risk for a stoma formation, including the above mentioned planned defunctioning stomas, was significantly lower in the RSI group than in the ASI group, (3 {0.94%} vs. 38 {10.7%}, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In the RSI group, all three stomas were reversed, while in the ASI group 30 of 38 stomas were reversed (3 {100%} vs. 30 {79%}, p\u0026thinsp;=\u0026thinsp;0.001). The mean number of weeks to stoma reversal was 21 weeks in the RSI group and 19 weeks in the ASI group (p\u0026thinsp;=\u0026thinsp;0.769). There was no mortality in either group. The univariate analysis is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Postoperative complications of patients in the RSI and ASI group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnmatched\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;903)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePropensity score matching (PSM)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;636)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRSI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eASI-G\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up\u003c/b\u003e (months, mean, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.8 (16\u0026ndash;125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.4 (16\u0026ndash;125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.5 (16\u0026ndash;125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68.4 (16\u0026ndash;125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall postoperative complication rate\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;patients, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e253 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e163 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMinor complications\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eClavien-Dindo I\u003c/p\u003e \u003cp\u003eClavien-Dindo II\u003c/p\u003e \u003cp\u003eClavien-Dindo IIIa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e234 (40%)\u003c/p\u003e \u003cp\u003e79 (14%)\u003c/p\u003e \u003cp\u003e133 (23%)\u003c/p\u003e \u003cp\u003e22 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (44%)\u003c/p\u003e \u003cp\u003e33 (10%)\u003c/p\u003e \u003cp\u003e91 (29%)\u003c/p\u003e \u003cp\u003e15 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003cp\u003e0.205\u003c/p\u003e \u003cp\u003e0.053\u003c/p\u003e \u003cp\u003e0.487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e133 (42%)\u003c/p\u003e \u003cp\u003e45 (14%)\u003c/p\u003e \u003cp\u003e76 (24%)\u003c/p\u003e \u003cp\u003e12 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e139 (44%)\u003c/p\u003e \u003cp\u003e33 (10%)\u003c/p\u003e \u003cp\u003e91 (29%)\u003c/p\u003e \u003cp\u003e15 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003cp\u003e0.183\u003c/p\u003e \u003cp\u003e0.207\u003c/p\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMajor complications, Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;IIIb\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eClavien-Dindo IIIb\u003c/p\u003e \u003cp\u003eAnastomotic leaks\u003c/p\u003e \u003cp\u003eIncisional hernias\u003c/p\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003cp\u003eAnastomositis\u003c/p\u003e \u003cp\u003ePostoperative acute appendicitis\u003c/p\u003e \u003cp\u003eFistula\u003c/p\u003e \u003cp\u003eStenosis of anastomosis\u003c/p\u003e \u003cp\u003eBowel obstruction\u003c/p\u003e \u003cp\u003eDislocation of Drainage into abdomen\u003c/p\u003e \u003cp\u003eClavien-Dindo IV\u003c/p\u003e \u003cp\u003eAnastomotic leaks\u003c/p\u003e \u003cp\u003eAllergic reaction\u003c/p\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003cp\u003eCatheter-associated Sepsis\u003c/p\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003cp\u003eClostridium difficile colitis\u003c/p\u003e \u003cp\u003eCardiac event\u003c/p\u003e \u003cp\u003eRenal failure\u003c/p\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (4.44%)\u003c/p\u003e \u003cp\u003e14 (2.40%)\u003c/p\u003e \u003cp\u003e6 (1.03%)\u003c/p\u003e \u003cp\u003e2 (0.34%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e3 (0.51%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e11 (1.88%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e2 (0.34%)\u003c/p\u003e \u003cp\u003e2 (0.34%)\u003c/p\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e3 (0.51%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (10%)\u003c/p\u003e \u003cp\u003e20 (6.29%)\u003c/p\u003e \u003cp\u003e5 (1.57%)\u003c/p\u003e \u003cp\u003e9 (2.83%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e12 (3.77%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003cp\u003e0.005\u003c/p\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (3.77%)\u003c/p\u003e \u003cp\u003e6 (1.89%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e6 (1.89%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (10%)\u003c/p\u003e \u003cp\u003e20 (6.29%)\u003c/p\u003e \u003cp\u003e5 (1.57%)\u003c/p\u003e \u003cp\u003e9 (2.83%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e12 (3.77%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e2 (0.63%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003cp\u003e1 (0.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003cp\u003e0.008\u003c/p\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eAnastomotic leaks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.17%)\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCCI (comprehensive complication index)\u003c/b\u003e (mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnastomotic leaks\u003c/b\u003e (N, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (1.37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (2.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (0.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (2.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of stomas\u003c/b\u003e (N, %)\u003c/p\u003e \u003cp\u003eHartmann procedure\u003c/p\u003e \u003cp\u003ePlanned\u003c/p\u003e \u003cp\u003eRevisional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (1.54%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003cp\u003e8 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (10.7%)\u003c/p\u003e \u003cp\u003e4 (1.3%)\u003c/p\u003e \u003cp\u003e27 (8.5%)\u003c/p\u003e \u003cp\u003e7 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.152\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (0.94%)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003cp\u003e2 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38 (10.7%)\u003c/p\u003e \u003cp\u003e4 (1.3%)\u003c/p\u003e \u003cp\u003e27 (8.5%)\u003c/p\u003e \u003cp\u003e7 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.152\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStoma reversal (N, %)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNumber of weeks to reversal (weeks, mean, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (88.89%)\u003c/p\u003e \u003cp\u003e21.25 (7\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (78.95%)\u003c/p\u003e \u003cp\u003e18.83 (2\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (100%)\u003c/p\u003e \u003cp\u003e21 (7\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30(78.95%)\u003c/p\u003e \u003cp\u003e18.83 (2\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePractical and helpful national and international guidelines on diverticular disease exist. They concur and provide clear recommendations regarding emergency surgery and recommend taking patients-related factors into consideration when surgery is up for debate. There also is consensus on elective surgery in patients with chronic complicated diverticulitis with fistula or stenosis [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]; however, there are some nuances amongst guidelines. The German guidelines recommend considering elective surgery in patients with smoldering diverticulitis (ongoing diverticulitis) after one episode of uncomplicated diverticulitis, and surgery should be offered to patients after conservatively or interventionally treated macroabscess (\u0026gt;\u0026thinsp;3cm). For patients with recurrent uncomplicated diverticulitis, the quality of life should serve as a decision-making aid for indication for elective surgery [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. In contrast, the ESCP (European Society of Coloproctolgy) do not differ between uncomplicated or acute complicated diverticulitis. The goal of the elective surgery is to improve quality of life. The indication is individualized based on frequencies of recurrences, duration and frequencies after attack of diverticulitis and co-morbidities of the patients [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, the WSES (World Society of Emergency Surgery) also focuses on the patient-related factors, but additionally, recommends planning elective surgery in immunosuppressed patients, which is not recommended in the German guidelines or by the ESCP [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows recommendations regarding elective sigmoidectomy in the most common national and international guidelines from the last decade.\u003c/p\u003e\n\u003cp\u003eNevertheless, in the elective setting the indication for surgery still remains vague. The guidelines are more and more reluctant with an indication for sigmoidectomy in recurrent diverticulitis or after a covered perforation. A recent snap-shot analysis across 49 Swiss hospitals showed that 82% of the sigmoidectomies for diverticular disease were performed for recurrent diverticulitis or after covered perforation [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to the current version of the German guidelines [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e], there is no indication for elective sigmoidectomy after microabscess (CDD IIa), whereas elective surgery may be offered to patients with a successfully conservatively treated macroabscess (CDD IIb). This is substantiated by the fact that one third of patients after a macroabscess will relapse within one year [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, a prospective observational trial demonstrated that within two years, 60% of patients with an initial microabscess (IIa) and 100% of patients with macroabscess (IIb) needed a sigmoidectomy due to relapse [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eA risk assessment for postoperative complications after elective sigmoidectomy in relation to patient-related factors and severity of disease does not exist. In this study, peri- and postoperative surgical outcomes in two homogenous groups after PSM of patients with different severity of indication requiring elective sigmoidectomy were compared. The study demonstrated that the risk profile in these two groups differ largely. Patients that underwent sigmoidectomy for recurrent diverticulitis or after microabscess (RSI) had an 11-fold decreased risk for the need of a defunctioning stoma, a 3-fold decreased risk for open surgery and a 2.6-fold decreased risk for major morbidity. In chronic complicated diverticulitis (ASI), the proportion of minimally invasive surgery was smaller and the intraoperative conversion rate to open surgery was higher (14% in ASI versus 5% in RSI). Other studies have reported conversion rates of between 2.3% and 23%, but with lack of consistent significant difference between complicated and uncomplicated diverticulitis [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe operation time was ten minutes longer in the ASI group compared to the RSI group. Although the difference is significant, its clinical relevance is negligible. Mizrahi et al. provided outcomes consistent with our results regarding surgery time, comparing patients with complicated versus uncomplicated diverticulitis (218min. vs. 185min.). However, no open procedures were performed in this study [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, Williams et al. investigated surgery duration in elective laparoscopic sigmoidectomy and showed a significant association between operation time and older age, greater BMI, concurrent hypertension and higher ASA classification, as well as the presence of dense adhesions intraoperatively, fistulas and abscesses. However, the data do not support pre-emptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our study shows similar association due to the presence of more severe diverticular disease with complicated diverticulitis in the ASI group (CDD Type IIb and IIIc). It is quite understandable that with more severe courses of disease, more difficult intraoperative situations are entailed. Nevertheless, our data also supports the laparoscopic approach if progress is safely being made, especially since intraoperative anesthesiological problems or complications are rare (0.3% in the ASI group).\u003c/p\u003e\n\u003cp\u003eIn the two groups, a comparably low incidence of intraoperative complications was observed (3% vs. 5% in RSI vs ASI, respectively), the most frequent being intraoperative bleeding in different locations (0.6% vs. 3.1% in RSI vs ASI, respectively). This might also be due to difficult scarring conditions in more severe disease courses in the ASI group. Other intraoperative complications were comparable to those reported in other studies for elective sigmoidectomy for diverticular disease [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThis study showed an overall complications rate of 44% in the RSI group and 51% in the ASI group (p\u0026thinsp;=\u0026thinsp;0.068). Similar rates were found in minor complications (Clavien-Dindo\u0026thinsp;\u0026lt;\u0026thinsp;IIIb) with 42% in the RSI group and 44% in the ASI group (p\u0026thinsp;=\u0026thinsp;0.689). Important to note, the analysis on postoperative complications in this study was performed very accurate and any documented deviation from normal course has been included in this study for analysis, and most of the complications were Clavien-Dindo I and II (38% in RSI vs. 39% in ASI). Therefore, in our point of view, this is the reason why the complications rate in this study is higher when compared to other studies [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. RSI patients showed a lower CCI compared with patients in the ASI group (9.4 vs. 12.9). Further data regarding the CCI in patients following elective sigmoidectomy for diverticulitis are currently non-existent.\u003c/p\u003e\n\u003cp\u003eIntriguingly, the results of postoperative major complications showed a difference between the analysed groups. In the RSI group, postoperative major complication occurred in 3.8% while 10% occurred in the ASI group. Most of the surgery-related complications were anastomotic leaks and incisional hernias. Mizrahi et al. provided a major complication rate of 1% in patients with uncomplicated diverticulitis and 3% in patients with complicated diverticulitis. However, it should be noted again that open surgery had been excluded [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, the largest case series by Jones et al. that included 500 laparoscopic resections, showed a postoperative major complication rate similar to this study of 11.5% in patients with complicated diverticulitis and 10.9% in patient with uncomplicated diverticulitis respectively, but without a statistically significant difference [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. On the other hand, Martel et al. reported that patients with severe disease experienced a significantly higher rate of surgical complications and general medical complications [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn the present study, 10.7% of ASI patients and 0.9% of RSI patients left the hospital with a stoma. In accordance with these findings, Martel et al. recorded a higher rate of defunctioning ileostomy in complicated versus uncomplicated disease (4.2% vs. 21%, respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Even higher rates of ileostomy creation were reported by Royds et al. (5.2% vs. 35%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. These results show an association with the progression of the disease and creation of ileostomy. Although creation of ileostomy is not considered a complication, it carries a considerable burden for the patients and may imply potential future complications to the stoma itself or to future surgery.\u003c/p\u003e\n\u003cp\u003eThe retrospective design is accompanied with an inherent risk of selection bias. Neither the follow-up, nor the hospital stay and quality of life were included in the data collected. One strength is the analysis, including most influential co-morbidities and the meticulous collection of data performed with the four-eyes principle. However, history of tobacco smoking, which is also known as a risk factor for complicated diverticulitis, was not recorded. Elective sigmoidectomy were performed or assisted by six highly experienced colorectal surgeons. Although institutional standard operating procedures (SOP) were strictly followed, potential operator bias due to possible differences between surgeons for treatment and surgical technique may exist.\u003c/p\u003e\n\u003cp\u003eWhen performing adequate benefit-risk assessment with every individual patient, it is of utmost importance to inquire about quality of life. Several studies investigating quality of life in patients with recurring or ongoing diverticulitis lend themselves to support the benefits of surgery. The DIRECT trial resulted in a significantly increase quality of life at five-year follow-up compared with conservative management and therefore supports surgery despite inherent risk of complications of operative management [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, the LASER trial comparing laparoscopic elective sigmoid resection with conservative treatment in a randomized setting showed a significant improvement of quality of life after surgery with a 10% risk of major complications [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study demonstrates that the surgical risk in terms of major complications, complications burden (CCI), risk of receiving a defunctioning stoma and the risk for the need of open surgery is distinctly different between recurring uncomplicated diverticulitis or after microabscess compared to more advanced disease stages such as after a macroabscess or in case of chronic complicated diverticulitis. The findings of this study will allow more tailored counseling when it comes to the shared decision making between patient and surgeon for or against elective sigmoidectomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no conflicts of interest.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The study was founded by institutional means.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e: Fabio Nocera and Fabian Haak wrote the main manuscript text, created tables and figures and collected most of the data. Alberto Posabella helped keep data files updated, performed limited data analysis and reviewed the manuscript. Most of the reviewing, coordination, rewriting and data analyses was completed by Fiorenzo Angehrn, Ralph Peterli and Daniel Steinemann. Beat M\u0026uuml;ller and Daniel Steinemann were responsible for the study design and coordination as well as for reviewing the manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: The illustrations were created by Lisa Cuthbertson.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eK\u0026ouml;hler L, Sauerland S, Neugebauer E (1999) Diagnosis and treatment of diverticular disease: Results of a consensus development conference. Surg Endosc 13:430\u0026ndash;436. https://doi.org/10.1007/s004649901007\u003c/li\u003e\n\u003cli\u003eAmbrosetti P, Robert JH, Witzig JA, et al (1994) Acute left colonic diverticulitis in young patients. J Am Coll Surg 179:156\u0026ndash;160\u003c/li\u003e\n\u003cli\u003eRose J, Parina RP, Faiz O, et al (2015) Long-term outcomes after initial presentation of diverticulitis. Ann Surg 262:1046\u0026ndash;1053. https://doi.org/10.1097/SLA.0000000000001114\u003c/li\u003e\n\u003cli\u003eRitz J-P, Lehmann KS, Frericks B, et al (2011) Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 149:606\u0026ndash;613. https://doi.org/10.1016/j.surg.2010.10.005\u003c/li\u003e\n\u003cli\u003eBoermeester MA, Humes DJ, Velmahos GC, S\u0026oslash;reide K (2016) Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis. World J Surg 40:2537\u0026ndash;2545. https://doi.org/10.1007/s00268-016-3560-8\u003c/li\u003e\n\u003cli\u003ePittet O, Kotzampassakis N, Schmidt S, et al (2009) Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis? World J Surg 33:547\u0026ndash;552. https://doi.org/10.1007/s00268-008-9898-9\u003c/li\u003e\n\u003cli\u003eLeifeld L, Germer CT, B\u0026ouml;hm S, et al (2014) [S2k guidelines diverticular disease/diverticulitis]. Z Gastroenterol 52:663\u0026ndash;710. https://doi.org/10.1055/s-0034-1366692\u003c/li\u003e\n\u003cli\u003eHoresh N, Wasserberg N, Zbar AP, et al (2016) Changing paradigms in the management of diverticulitis. Int J Surg 33 Pt A:146\u0026ndash;150. https://doi.org/10.1016/j.ijsu.2016.07.072\u003c/li\u003e\n\u003cli\u003eLeifeld L, Germer CT, B\u0026ouml;hm S, et al (2022) S3-Leitlinie Divertikelkrankheit/Divertikulitis-Gemeinsame Leitlinie der Deutschen Gesellschaft f\u0026uuml;r Gastroenterologie, Verdauungs-und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft f\u0026uuml;r Allgemein-und Viszeralchirurgie (DGAV). Z Gastroenterol 60:613\u0026ndash;688. https://doi.org/10.1055/a-1741-5724\u003c/li\u003e\n\u003cli\u003evan de Wall BJM, Stam MAW, Draaisma WA, et al (2017) Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2:13\u0026ndash;22. https://doi.org/10.1016/S2468-1253(16)30109-1\u003c/li\u003e\n\u003cli\u003eSantos A, Mentula P, Pinta T, et al (2021) Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized Clinical Trial. JAMA Surg 156:129\u0026ndash;136. https://doi.org/10.1001/jamasurg.2020.5151\u003c/li\u003e\n\u003cli\u003eSchultz JK, Azhar N, Binda GA, et al (2020) European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Disease 22:5\u0026ndash;28. https://doi.org/10.1111/codi.15140\u003c/li\u003e\n\u003cli\u003eSartelli M et al. (2020) 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergeny setting. World J Emerg Surg. https://doi.org/https://doi.org/10.1186/s13017-020-00313-4\u003c/li\u003e\n\u003cli\u003eGaletin T, Galetin A, Vestweber K-H, Rink AD (2018) Systematic review and comparison of national and international guidelines on diverticular disease. Int J Colorectal Dis 33:261\u0026ndash;272. https://doi.org/10.1007/s00384-017-2960-z\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205\u0026ndash;213. https://doi.org/10.1097/01.sla.0000133083.54934.ae\u003c/li\u003e\n\u003cli\u003eSlankamenac K, Graf R, Barkun J, et al (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1\u0026ndash;7. https://doi.org/10.1097/SLA.0b013e318296c732\u003c/li\u003e\n\u003cli\u003eR Core Team (2021) A language and environment for statistical computing\u003c/li\u003e\n\u003cli\u003eFaes S, H\u0026uuml;bner M, Demartines N, et al (2021) Elective Surgery for Diverticulitis in Swiss Hospitals. Front Surg 8:717228. https://doi.org/10.3389/fsurg.2021.717228\u003c/li\u003e\n\u003cli\u003eLauscher JC, Lock JF, Aschenbrenner K, et al (2021) Validation of the German Classification of Diverticular Disease (VADIS)-a prospective bicentric observational study. Int J Colorectal Dis 36:103\u0026ndash;115. https://doi.org/10.1007/s00384-020-03721-9\u003c/li\u003e\n\u003cli\u003eJones OM, Stevenson ARL, Clark D, et al (2008) Laparoscopic resection for diverticular disease: follow-up of 500 consecutive patients. Ann Surg 248:1092\u0026ndash;1097. https://doi.org/10.1097/SLA.0b013e3181884923\u003c/li\u003e\n\u003cli\u003eRoyds J, O\u0026rsquo;Riordan JM, Eguare E, et al (2012) Laparoscopic surgery for complicated diverticular disease: a single-centre experience. Colorectal Dis 14:1248\u0026ndash;1254. https://doi.org/10.1111/j.1463-1318.2011.02924.x\u003c/li\u003e\n\u003cli\u003eMartel G, Bouchard A, Soto CM, et al (2010) Laparoscopic colectomy for complex diverticular disease: a justifiable choice? Surg Endosc 24:2273\u0026ndash;2280. https://doi.org/10.1007/s00464-010-0951-z\u003c/li\u003e\n\u003cli\u003eMizrahi I, Abu-Gazala M, Fernandez LM, et al (2021) Elective minimally invasive surgery for sigmoid diverticulitis: operative outcomes of patients with complicated versus uncomplicated disease. Colorectal Dis 23:2948\u0026ndash;2954. https://doi.org/10.1111/codi.15837\u003c/li\u003e\n\u003cli\u003eWilliams J, Stocchi L, Aiello A, et al (2021) No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease. Surg Endosc 35:2823\u0026ndash;2830. https://doi.org/10.1007/s00464-020-07717-y\u003c/li\u003e\n\u003cli\u003eRaskin ER, Keller DS, Gorrepati ML, et al (2019) Propensity-Matched Analysis of Sigmoidectomies for Diverticular Disease. JSLS 23:. https://doi.org/10.4293/JSLS.2018.00073\u003c/li\u003e\n\u003cli\u003eBouillot JL, Berthou JC, Champault G, et al (2002) Elective laparoscopic colonic resection for diverticular disease: results of a multicenter study in 179 patients. Surg Endosc 16:1320\u0026ndash;1323. https://doi.org/10.1007/s00464-001-9236-x\u003c/li\u003e\n\u003cli\u003eIlyas MIM, Zangbar B, Nfonsam VN, et al (2017) Are there differences in outcome after elective sigmoidectomy for diverticular disease and for cancer? A national inpatient study. Colorectal Dis 19:260\u0026ndash;265. https://doi.org/10.1111/codi.13461\u003c/li\u003e\n\u003cli\u003eSartelli M, Viale P, Catena F, et al (2013) 2013 WSES guidelines for management of intra-abdominal infections. World Journal of Emergency Surgery 8:1\u0026ndash;29. https://doi.org/10.1186/1749-7922-8-3\u003c/li\u003e\n\u003cli\u003eSartelli M, Catena F, Ansaloni L, et al (2016) WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 11:37. https://doi.org/10.1186/s13017-016-0095-0\u003c/li\u003e\n\u003cli\u003eAndeweg CS, Mulder IM, Felt-Bersma RJF, et al (2013) Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 30:278\u0026ndash;292. https://doi.org/10.1159/000354035\u003c/li\u003e\n\u003cli\u003eBinda GA, Cuomo R, Laghi A, et al (2015) Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 19:615\u0026ndash;626. https://doi.org/10.1007/s10151-015-1370-x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Diverticulitis, elective surgery, surgical outcomes, classification","lastPublishedDoi":"10.21203/rs.3.rs-2939249/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2939249/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWeighing the perioperative risk of elective sigmoidectomy is done regardless of the specific diverticulitis classification. The aim of this study is to evaluate surgical outcomes according to the classification grade and the indication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients who underwent elective surgery for diverticulitis between 2011 and 2020 were included. They were divided into two groups: relative surgery indication (RSI) and absolute surgery indication (ASI). RSI included microabscess and recurrent uncomplicated disease. ASI included macroabscess and recurrent complicated disease. Propensity score-matching (PSM, 1:1) was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCriteria for RSI were fulfilled in 585npatients and for ASI in 318. After PSM, 318 RSI vs. 318 ASI patients were selected; baseline characteristics results were comparable. The proportion of planned laparoscopic resection was 93% in RSI versus 75% in ASI (p\u0026lt;0.001), and the conversion rate to open surgery for laparoscopic resection was 5.0% and 13.8% in RSI versus ASI (p\u0026lt;0.001). Major morbidity (Clavien/Dindo ≥IIIb) occurred less frequently in RSI (3.77% vs. 10%, p=0.003). A defunctioning stoma was formed in 0.9% and 11.0% in RSI vs ASI, respectively (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe lower risk for postoperative morbidity, the higher chance for a laparoscopic resection and the decreased rate of stoma formation are attributed to patients with recurrent uncomplicated diverticulitis or diverticulitis including a microabscess as compared to patients with complicated diverticulitis or diverticulitis and a macroabscess, and this applies even after PSM. Knowledge of stage-specific perioperative risk is important in determining indications and counseling patients.\u003c/p\u003e","manuscriptTitle":"Surgical outcomes in elective sigmoid resection for diverticulitis stratified according to indication: a propensity-score matched cohort study with 903 patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-19 15:08:32","doi":"10.21203/rs.3.rs-2939249/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-06-18T01:34:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-05-22T06:23:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e345d6bd-fbb2-44af-bda8-ecd3b00fe6df","date":"2023-05-19T12:38:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-19T07:47:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-05-18T09:03:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-05-17T22:25:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2023-05-15T19:50:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4e500ab2-a252-4986-8e2c-a8b79cc0768e","owner":[],"postedDate":"May 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T22:11:23+00:00","versionOfRecord":{"articleIdentity":"rs-2939249","link":"https://doi.org/10.1007/s00423-023-03034-9","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2023-08-03 21:50:23","publishedOnDateReadable":"August 3rd, 2023"},"versionCreatedAt":"2023-05-19 15:08:32","video":"","vorDoi":"10.1007/s00423-023-03034-9","vorDoiUrl":"https://doi.org/10.1007/s00423-023-03034-9","workflowStages":[]},"version":"v1","identity":"rs-2939249","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2939249","identity":"rs-2939249","version":["v1"]},"buildId":"DfRiq_wiF3Ryq-tyrab2w","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}