Quality of life after conservative versus elective surgical management of first-episode uncomplicated diverticulitis: a single-center prospective study

Quality of life after conservative versus elective surgical management of first-episode uncomplicated diverticulitis: a single-center prospective study | 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 Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quality of life after conservative versus elective surgical management of first-episode uncomplicated diverticulitis: a single-center prospective study Giuseppe Quero, Lodovica Langellotti, Antonio Pio Tortorelli, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9303452/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Optimal long-term management after a first episode of uncomplicated acute diverticulitis (AD) remains debated. Quality of life (QoL) is increasingly recognized as a key outcome to guide individualized decision-making between clinical surveillance and elective sigmoid resection. Methods This single-center prospective longitudinal observational study enrolled adults with a first episode of uncomplicated AD (Hinchey 0-1a). After recovery from the index episode, patients underwent either clinical follow-up (non-surgery group) or elective laparoscopic sigmoidectomy (surgery group) according to routine clinical decision-making. Diverticulitis-specific QoL was assessed using the DV-QoL questionnaire, retrospectively referring to the month before the index episode and prospectively at 1, 6, and 12 months after post-episode management. The primary aim was to describe and compare DV-QoL trajectories between groups. A DV-QoL score ≥ 3.2 was used to define a non-acceptable symptom state (PASS threshold). Predictors of non-acceptable QoL were explored in conservatively managed patients. Results A total of 137 patients were included: 96(70%) in the non-surgery group and 41(30%) in the surgery group. Baseline characteristics were comparable. Pre-episode DV-QoL scores were similar between groups (0.19 ± 0.29 vs 0.12 ± 0.33; p = 0.14). DV-QoL total scores were significantly higher (worse QoL) in the non-surgery group at 1 month (2.60 ± 2.70 vs 0.11 ± 0.15; p < 0.001), 6 months (2.09 ± 2.24 vs 0.05 ± 0.12; p < 0.001), and 12 months (1.92 ± 2.07 vs 0.02 ± 0.07; p < 0.001). Non-acceptable QoL (PASS ≥ 3.2) occurred only in the non-surgery cohort at all time points, whereas no surgical patient exceeded PASS. Younger age independently predicted non-acceptable QoL in conservatively managed patients. Conclusion Elective laparoscopic sigmoidectomy after a first uncomplicated AD episode was associated with sustained improvements in disease-specific QoL compared with clinical follow-up. Routine DV-QoL assessment may help identify patients at risk of persistent impairment and optimize individualized surgical decision-making. diverticular disease quality of life DV-QoL uncomplicated diverticular disease elective sigmoidectomy diverticulosis Figures Figure 1 Introduction Diverticulosis is an asymptomatic clinical condition affecting approximately 50% of individuals over the age of 60 in the United States [ 1 , 2 ]. According to recent studies, about 5% of patients with diverticulosis will develop acute diverticulitis (AD) over time, defined as an inflammatory process of the colon resulting from inflammation of diverticula with or without associated complications [ 1 – 3 ]. This condition accounts for nearly 300,000 hospital admissions annually, with an estimated economic burden of approximately 9 billion dollars on the national healthcare system [ 4 , 5 ]. From a clinical standpoint, AD can be categorized into uncomplicated and complicated forms [ 6 ]. The uncomplicated form is characterized by acute inflammation of the colonic wall and pericolic fat, in the absence of radiological or clinical signs of abscess, perforation, fistula, or stricture. In contrast, the complicated form refers to diverticular inflammation associated with one or more complications, including pericolic abscess, perforation, fistula formation, stricture, or diverticular bleeding. The uncomplicated form of AD accounts for approximately 75–85% of all cases of diverticulitis [ 6 ]. In accordance with the most recent international guidelines [ 3 , 7 – 10 ], the management of uncomplicated AD is primarily conservative, consisting of bowel rest and intravenous fluid therapy, with or without antibiotic treatment depending on the patient’s general clinical condition and comorbidities. However, although most patients experiencing a first episode of uncomplicated AD do not develop further episodes, approximately 8% have a risk of recurrence within one year, 19% experience a second recurrence, and 24% will have an additional episode after the third recurrence [ 3 , 7 – 10 ]. This evidence continues to fuel the debate in the literature regarding the optimal management strategy after an episode of uncomplicated AD, by evaluating the potential benefits of elective surgical treatment following the resolution of the first episode of acute uncomplicated AD. Previous recommendations supported elective surgical resection only after multiple episodes of AD or in cases of acute inflammatory diverticular disease occurring at a young age [ 11 ]. However, more recent guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) [ 12 ] and the World Society of Emergency Surgery (WSES) [ 13 ] advocate for a case-by-case approach, emphasizing an individualized risk–benefit evaluation when considering long-term management options—whether clinical surveillance or elective surgical intervention—after a first episode of uncomplicated AD. In this context, the assessment of quality of life (QoL) is progressively gaining a predominant role, representing a key element in defining the overall impact of the disease on the patient’s daily life and serving as an essential tool to determine the most appropriate management strategy [ 14 ]. Based on these premises, the aim of this prospective study is to evaluate the QoL of patients following a first episode of uncomplicated AD treated conservatively, and subsequently managed either with clinical follow-up or elective surgical resection, in order to determine the most appropriate therapeutic strategy. Materials and Methods Study design and data collection This was a single-center, prospective, longitudinal, observational study conducted at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS of Rome between January 2021 and December 2023. The study was approved by the Institutional Ethics Committee (ID: 4522 Prot N. 0030679/21) and carried out in accordance with the Declaration of Helsinki. Only patients aged 18 years or older who admitted to the Emergency Department or the Digestive Surgery Unit of the Fondazione Policlinico Gemelli IRCCS with a clinical and radiological diagnosis of a first episode of uncomplicated AD were prospectively enrolled. Exclusion criteria were previous history of emergency surgery, previous abdominal operations, prior episodes of acute diverticulitis, and/or diagnosis of inflammatory bowel disease. AD was graded according to the modified Hinchey classification [ 13 ]. Accordingly, only patients with a grade 0 and 1a (corresponding to uncomplicated AD) were enrolled in the study. All recruited patients underwent conservative treatment according to the current guidelines [ 12 – 13 , 15 – 16 ] until complete resolution of the clinical condition. After resolution of the index episode, patients entered routine post-diverticulitis management and were classified according to the strategy actually undertaken: clinical follow-up or elective sigmoidectomy. Treatment allocation was not protocolized and was not randomized. The decision to proceed with surgery was made within routine clinical practice by the treating surgical team, based on an individualized assessment that included patient preference and physician judgement. All patients considered for surgery underwent standard preoperative counselling and provided written informed consent for the surgical procedure. The following clinic-demographic characteristics were prospectively collected: age, sex, body mass index (BMI), smoking status, and comorbidities (also stratified for Charlson Comorbidity Index (CCI) [ 17 ]). For the surgery group, additional perioperative variables were retrieved, including surgical approach (open or laparoscopic), operative time, need for ostomy, postoperative complications (including anastomotic leakage), postoperative mortality, and length of hospital stay. Post-operative complications were graded according to the Clavien-Dindo classification [ 18 ], while post-operative mortality was defined as any death occurring during the hospitalization. Anastomotic leakage was defined and classified according to the International Study Group of Rectal Cancer (ISGRC) classification [ 19 ]. Study outcomes The primary outcome of the study was to assess and compare QoL between patients who underwent clinical follow up (non-surgery group) and those who underwent elective laparoscopic sigmoidectomy (surgery group) after a first episode of uncomplicated AD (Hinchey 0-1a) managed conservatively. Quality of Life (QoL) assessment The Diverticulitis Quality of Life (DV-QOL) questionnaire The DV-QOL (Diverticulitis Quality of Life) instrument is a disease-specific tool designed to assess the impact of AD on patients’ QoL. It includes 17 items distributed across four domains: physical symptoms (5 items), concerns (3 items), feelings (4 items), and behavioural changes (5 items) [ 20 – 22 ]. For the non-surgery group, DV-QoL was collected at 1, 6, and 12 months after the index diverticulitis episode. For the surgery-group, DV-QoL was collected at 1, 6, and 12 months after elective sigmoidectomy. Therefore, follow-up assessments were anchored to different post-episode milestones across groups rather than to a common time origin, and comparisons should be interpreted as reflecting QoL after the management strategy actually undertaken rather than strictly time-matched outcomes after the index episode. This reflects real-world decision-based outcomes rather than strictly time-aligned comparisons. In order to assess the baseline gastrointestinal status before the first episode of AD, all patients were also asked to complete the DV-QoL questionnaire referring to one month before their first episode. Scoring Each domain score is derived by converting the sum of item responses into a 0–10 normalized scale, where lower values reflect better quality of life. The overall DV-QOL score is calculated summarizing the four domain scores, with each domain contributing equally, as described by Khor et al. [ 23 ]. A Patient Acceptable Symptom State (PASS) threshold of 3.2 has been established: scores < 3.2 correspond to an acceptable symptom burden, whereas scores ≥ 3.2 indicate symptom levels associated with a clinically relevant reduction in QoL [ 23 ]. Surgical and non-surgical treatments All patients included in the study underwent conservative management consisting of fasting, parenteral nutrition, and intravenous or oral antibiotic therapy according to clinical conditions and in accordance with current guidelines [ 12 – 13 , 15 – 16 ], until resolution of the clinical picture. During this period, a gradual reintroduction of oral feeding was undertaken, with discharge on a full diet once clinical resolution was achieved. Per protocol, at discharge, all patients were prescribed a standard therapy consisting of oral neomycin and probiotics, to be administered in one-week cycles per month, regardless of any recurrence of symptoms, together with a disease-specific diet for diverticular disease. Patients in the non-surgical group underwent clinical follow-up, while patients in the surgical group were electively scheduled for laparoscopic sigmoidectomy. The procedure followed the standard steps of sigmoidectomy, including isolation and division of the sigmoid vessels, distal resection at the rectosigmoid junction using a triple-row linear stapler, proximal transection at the descending colon–sigmoid junction, and end-to-end colorectal anastomosis using a triple-row circular stapler. In all cases, a hydro-pneumatic leak test of the anastomosis was performed, and the creation of a protective ileostomy was left to the discretion of the operating surgeon or in case of positive hydro-pneumatic leak test. Postoperatively, adequate analgesic therapy was administered throughout the hospital stay, along with supportive intravenous fluid therapy for the first 12 hours. Patients resumed a liquid diet 24 hours after surgery, progressing to regular oral intake according to the clinical conditions. Laboratory tests, including blood chemistry and complete blood count, were performed on postoperative days 1, 3, and 5. Discharge occurred upon restoration of regular oral intake and bowel function (passage of gas and/or stool), in the absence of fever or abnormalities in laboratory findings. Statistical analysis Continuous data were reported as mean ± standard deviation (± SD), while categorical data as number and percentages. Univariate analysis was performed with Student’s t tests, Mann-Whitney U tests, Fisher’s tests and χ 2 test. For all analyses, a p value ≤ 0.05 was considered as statistically significant. Post-hoc statistical power was calculated using the observed effect sizes derived from paired mean differences (Cohen’s d) for the primary endpoint. Power estimates were obtained using standard analytical methods under α = 0.05 and number of patients involved. To explore potential non-linear associations between age and QoL in relation to study outcomes, QoL was modeled using restricted cubic splines. Expected QoL values were derived from the beta coefficients of multivariate linear regression models and plotted against age. Adjusted predicted QoL at 6 and 12 months was estimated from model-based predictions and displayed according to operative intent (resection vs clinical follow-up). A restricted cubic spline (RCS) curve was fitted to describe this relationship, using age as a continuous predictor and adjusted predicted QoL as the outcome. This non-parametric approach was selected to provide a flexible representation of the association without imposing a predefined parametric form. Knots were placed at the 25th, 50th, and 75th percentiles of the age distribution, following standard recommendations for spline modeling. These graphical analyses were intended as descriptive tools to aid interpretation and were not used for inferential testing or hypothesis evaluation. To identify independent predictors of poor quality of life (DV-QoL ≥ 3.2), we included in a logistic regression model all variables that were significant in the univariate analysis. Since all patients who underwent surgical resection achieved a satisfactory QoL outcome, we performed a sensitivity analysis restricted to patients managed conservatively. Results of the logistic regression analysis are reported as odds ratios (ORs) with 95% confidence intervals. All tests were performed using SPSS version 25 for Windows (SPSS Inc., Chicago, IL, United States). Results Demographical and clinical characteristic of the population A total of 137 patients were enrolled in the study: 96 (70%) underwent clinical follow-up after the first episode of uncomplicated AD and constituted the non-surgery group, while 41 (30%) underwent surgery after the conservative treatment and constituted the surgery cohort ( Figure S1 ). Baseline demographic and clinical characteristics of the study population are reported in Table 1 . No statistically significant differences were detected between the two study cohorts in terms of sex, age and BMI. Similarly, the two study cohorts were comparable for major comorbidities, expect for pulmonary diseases, more frequently encountered in the surgery cohort (3 -7.3%) as compared to the non-surgery group (1–1%) (p = 0.05). The distribution of Hinchey grades at presentation was comparable between groups, with the majority of patients classified as Hinchey 1a (73–76% and 31–75.6% in the non-surgery and surgery groups, respectively; p = 0.95). Table 1 Demographical and clinical characteristics of the study groups. Sex, n (%) Population (n = 137) Non-surgery (n = 96) Surgery (n = 41) p M 60 (43.8) 37 (38.5) 23 (56.1) 0.06 F 77 (56.2) 59 (61.5) 18 (43.9) Age, years, mean ± SD 59 ± 13 59 ± 13 66 ± 15 0.97 BMI, mean ± SD 24.5 ± 4 24.4 ± 4 23.5 + 2 0.63 Cardiovascular comorbidities, n (%) 67 (49) 45 (47) 22 (53) 0.47 Diabetes, n (%) 6 (4.4) 6 (6.2) 0 0.10 Pulmonary comorbidities, n (%) 1 (0.7) 1 (1) 3 (7.3) 0.05 Charlson Comorbidity Index , mean ± SD 1.63 ± 1.41 1.73 ± 1.54 1.39 ± 1.04 0.13 Smoker or ex-smoker, n (%) 48 (35) 36 (37) 12 (30) 0.33 Hinchey grade, n (%) 0 33 (24.1) 23 (24) 10 (24.4) 0.95 1a 104 (75.9) 73 (76) 31 (75.6) Surgery group and post-operative outcome Intraoperative features and postoperative outcomes of the surgical group are summarized in Table 2 . Surgery was performed after a mean time of 3.1 + 1.1 months after the first episode of AD. No AD recurrence was documented before surgery. No intraoperative conversions were recorded. An ostomy was required in one patient (2.4%) for a positive hydro-pneumatic leak test. Postoperative morbidity was low, with 4 patients (9.7%) experiencing Clavien–Dindo grade I–II complications, while no major adverse events (grade III–IV) were observed in any case. No anastomotic leakage or in-hospital mortality occurred. Incisional hernia was reported in 2 patients (4.9%). The mean length of hospital stay was 6 ( ± 2) days. Table 2 Intraoperative and surgical outcomes of the surgery group Surgery group (n = 41) Intra-operative outcomes Conversion rate, n (%) 0 Ostomy, n (%) 1 (2.4) Post-operative outcomes Clavien-Dindo, n (%) I-II 4 (9.7) III-IV 0 Anastomotic leakage, n (%) 0 Incisional hernia, n (%) 2 (4.9) In-hospital mortality, n (%) 0 Length of hospital stay, days, mean ± SD 6 ± 2 Non-surgery group Of the 96 patients managed conservatively,14 patients (14.6%) experienced AD recurrence after a mean time of 9 ± 3.2 months after the first AD episode. Among these, 6 (42.8%) patients presented a Hichey grade 0-1a, 6 (42.8%) a grade 1b, and 2 (14.4%) and Hinchey 4 AD that required emergency surgical intervention with colostomy formation. The remaining recurrences were managed conservatively without the need for urgent surgery. QoL comparison between surgery and no-surgery group DV-QoL scores, at one month before the AD episode (baseline measure), were comparable between the non-surgery and surgery cohorts, with a value of 0.19 ± 0.29 and 0.12 ± 0.33, respectively (p = 0.14). Conversely, DV-QoL questionnaire scores were significantly lower in patients undergoing surgery compared with those managed only conservatively at all evaluated follow-up time points (Table 3 ). At 1 month, the non-surgery group reported a significantly higher mean DV-QoL score compared with the surgical group (2.60 ± 2.7 vs 0.11 ± 0.15, respectively; p < 0.001), indicating a worse QoL. Similarly, at 6 months, DV-QoL scores remained significantly higher in the non-surgery group than in the surgery cohort (2.09 ± 2.24 vs 0.05 ± 0.12, respectively; p < 0.001). This difference persisted at 12 months, with the non-surgery patients reporting worse DV-QoL scores compared with those who underwent elective surgery (1.92 ± 2.07 vs 0.02 ± 0.07, respectively; p < 0.001). Table 3 Comparison of DV-QoL questionnaire scores at 1-, 6-, and 12-months between surgery and non-surgery groups Time point Non-surgery group (n = 96) Surgery group (n = 41) p Effect size (Cohen’s d) Baseline, mean ± SD 0.19 ± 0.29 0.12 ± 0.33 0.14 1.01 1-month, mean ± SD 2.60 ± 2.7 0.11 ± 0.15 < 0.001 1.10 6-months, mean ± SD 2.09 ± 2.24 0.05 ± 0.12 < 0.001 1.08 12-months, mean ± SD 1.92 ± 2.07 0.02 ± 0.07 1.0), indicating a sustained benefit of surgical treatment on disease-related QoL over time. Overall, the analysis of DV-QoL subdomains showed a robust and sustained advantage of surgical treatment over conservative management at all the follow-up time points, with statistically significant differences consistently observed across every domain and individual questionnaire item ( Table S1 ). Patients were, thus, categorized according to the PASS threshold (Table 4 ). At 1-month, a DV-QoL questionnaire score > 3.2 was documented in 32 (33.3%) patients of the non-surgery cohort as compared to none in the surgery group (p 3.2 in the non-surgery and surgery cohorts, respectively; p 3.2 in the non-surgery and surgery cohorts, respectively; p < 0001) analyses. Table 4 QoL comparison between non-surgery and surgery treatments according to the DV-QoL questionnaire PASS threshold Time point Non-surgery (n = 96) Surgery (n = 41) p 1 month follow-up DV-QoL score ≤ 3.2, n (%) 64 (66.7) 41 (100) 3.2, n (%) 32 (33.3) 0 (0) 6 months follow-up DV-QoL score ≤ 3.2, n (%) 69 (71.9) 41 (100) 3.2, n (%) 27 (28.1) 0 (0) 12 months follow-up DV-QoL score ≤ 3.2, n (%) 71 (74) 41 (100) 3.2, n (%) 25 (26) 0 (0) Multivariate analysis of prognostic factors for PASS threshold ≥ 3.2 in the non-surgery group A multivariable analysis was performed to identify factors associated with unacceptable QoL (PASS ≥ 3.2) in conservatively managed patients. ( Table 5 ) . Table 5 Multivariate analysis of factors associated with non-acceptable DV-QoL (≥ 3.2) in the non-surgery group Variables 1-month PASS threshold Multivariate analysis odds ratio [95% Confidence Interval] < 3.2 (n = 64) ≥ 3.2 (n = 32) p p Age < 57 27 (42) 24 (58) 0.002 0.28 [0.11–0.71] 0.04 ≥ 57 37 (58) 8 (42) Sex M 26 (40) 11 (35) 0.55 - - F 38 (60) 21 (65) BMI < 24 34 (53) 13 (46) 0.23 - - ≥ 24 26 (46) 17 (53) CCI < 1 27 (42) 22 (68) 0.01 0.83 [0.22–3.12] 0.78 ≥ 1 37 (58) 10 (32) Hinchey grade 0 14 (22) 9 (28) 0.49 1 a 50 (78) 23 (72) 6-months PASS threshold Multivariate analysis odds ratio [95% Confidence Interval] Variables < 3.2 (n = 69) ≥ 3.2 (n = 27) p p Age < 57 32 (46) 19 (70) 0.03 - - ≥ 57 37 (54) 8 (30) Sex M 29 (42) 8 (30) 0.26 - - F 40 (58) 19 (70) BMI < 24 34 (49) 13 (50) 0.78 - - ≥ 24 30 (41) 13 (50) CCI < 1 32 (46) 6 (33) 0.14 - - ≥ 1 37 (54) 10 (37) Hinchey grade 0 17 (25) 6 (33) 0.8 1 a 52 (75) 21 (77) 12-months PASS threshold Multivariate analysis odds ratio [95% Confidence Interval] Variables < 3.2 (n = 71) ≥ 3.2 (n = 25) p p Age < 57 35 (49) 16 (64) 0.2 - - ≥ 57 36 (41) 9 (36) Sex M 28 (39) 9 (36) 0.76 - - F 43 (61) 16 (64) BMI < 24 35 (49) 12 (48) 0.62 - - ≥ 24 30 (41) 13 (52) CCI < 1 34 (48) 15 (60) 0.29 - - ≥ 1 37 (52) 10 (40) Hinchey grade 0 19 (27) 4 (16) 0.27 - - 1 a 52 (73) 21 (84) At 1-month of follow-up, unacceptable DV-QoL (PASS ≥ 3.2) was observed in 32 patients (23.4%). Univariate analysis showed that only younger age (p = 0.002) and a CCI < 1 (p = 0.01) were significantly associated to a worse QoL. At the multivariable analysis, only age remained an independent predictor of unacceptable quality of life (OR 0.28, 95% CI 0.11–0.71; p = 0.04). At 6 months, only younger age was significantly associated to a PASS value ≥ 3.2 (p = 0.03) at the univariate analysis, while none of the clinico-demographic features significantly influenced QoL at the 12-month evaluation. Age-related distribution of DV-QoL scores ( Fig. 1 ) Scatter plots with smoothing curves were used to descriptively assess the relationship between age and DV-QoL scores at 6 and 12 months according to treatment strategy. Across the entire age range, patients managed conservatively consistently exhibited higher DV-QoL scores compared with those undergoing elective surgery, indicating worse disease-related QoL. In the non-surgical group, DV-QoL scores showed greater dispersion and a non-linear trend across age, with persistently elevated values at both younger and older ages. Conversely, surgically treated patients demonstrated uniformly lower DV-QoL scores with minimal variability and a relatively flat trend across age. This visual separation between groups persisted at both 6- and 12-month follow-up, supporting the robustness and durability of the observed differences in QoL. Discussion In this prospective longitudinal study, we investigated diverticulitis-specific QoL after a first episode of uncomplicated AD treated conservatively, comparing subsequent clinical surveillance versus elective laparoscopic sigmoid resection. The principal finding is that elective surgery was associated with a marked and sustained benefit in disease-related QoL: surgically treated patients exhibited near-zero DV-QoL scores at 1, 6, and 12 months, and none exceeded the PASS threshold across follow-up. Conversely, patients managed conservatively reported persistently higher DV-QoL values, with approximately one-third experiencing a non-acceptable symptom state at 1 month and roughly one-quarter still above PASS at 12 months. Overall, these results suggest that, even after a first uncomplicated episode, a clinically relevant subgroup experiences prolonged impairment that is not adequately captured by traditional endpoints such as radiologic resolution or recurrence alone. Over recent years, international recommendations have progressively moved away from elective resection based solely on the number of acute episodes, advocating instead for individualized decision-making after recovery from uncomplicated AD [ 24 ]. This approach is reflected in the European Society of Coloproctology (ESCP) guidelines, which emphasize patient-centered evaluation—including symptom burden and QoL—when considering elective surgery for diverticular disease [ 25 ]. In this framework, our findings provide evidence that the impact of uncomplicated diverticulitis may extend beyond the acute inflammatory event itself, resulting in persistent symptoms, concerns, and behavioral limitations over months. This perspective supports structured follow-up strategies aimed at identifying patients who do not return to an acceptable health state despite conservative management. Our results are consistent in direction with randomized evidence comparing elective sigmoid resection and conservative management for diverticular disease, where surgery has been associated with improved QoL. The LASER randomized clinical trial reported superior QoL outcomes with elective laparoscopic sigmoid resection compared with conservative treatment in patients with recurrent, complicated, or persistent painful diverticulitis [ 26 ]. This advantage was maintained at 2-year follow-up and was accompanied by reduced recurrence rates, reinforcing the durability of the surgical benefit [ 27 ]. Similarly, the DIRECT multicenter randomized trial demonstrated that elective sigmoidectomy improved QoL compared with conservative management in patients with recurrent diverticulitis or ongoing complaints after an episode of diverticulitis, with long-term follow-up supporting sustained benefits in patient-reported outcomes [ 28 , 29 ]. Although the populations of LASER and DIRECT [ 26 – 29 ] differ from ours—primarily including recurrent or persistent symptomatic disease rather than a “first uncomplicated episode”—their findings support the concept that elective resection may yield meaningful patient-centered benefits when diverticular disease has a significant impact on daily life. Our study extends this paradigm earlier along the disease timeline, indicating that relevant QoL impairment can occur even after the first uncomplicated episode in a sizeable proportion of patients. A major strength of our study compared to much of the existing literature is the use of the DV-QoL questionnaire, a validated diverticulitis-specific patient-reported outcome measure designed to capture domains that are uniquely relevant to diverticular disease, including physical symptoms, concerns, emotional well-being, and behavioural changes [ 30 ]. This is particularly relevant when interpreting the literature, as several prior surgical trials have relied primarily on generic QoL tools such as GIQLI, SF-36, and/or EQ-5D, which provide valuable global assessment but may be less sensitive to disease-specific limitations and coping behaviours typical of diverticulitis [ 31 , 32 ]. In contrast, DV-QoL provides a more granular assessment of diverticulitis-related impairment and offers an additional advantage: clinically interpretable thresholds. Khor et al. established the PASS threshold (≥ 3.2) and minimal clinically important difference (MCID) for DV-QoL, allowing meaningful translation of PROM values into patient-acceptable versus non-acceptable symptom states [ 23 ]. Within this conceptual framework, our PASS-based analysis revealed that a relevant subgroup of conservatively managed patients remained in a non-acceptable symptom state even at 12 months, highlighting a “hidden burden” that might be underestimated when focusing only on recurrence or generic QoL scores. Importantly, the benefit of surgery in our cohort was not limited to DV-QoL total score but was consistently observed across DV-QoL domains, suggesting a multidimensional effect of elective resection. While symptom control is likely the main driver, the sustained differences in concerns, emotional well-being, and behavioural changes suggest that surgery may mitigate the broader psychosocial burden of diverticulitis, including fear of recurrence, persistent dietary restrictions, and social or occupational limitations. This is consistent with the modern patient-centered perspective of diverticular disease, in which the goal is not only preventing acute inflammatory relapses but also restoring long-term daily functioning and well-being. Another clinically relevant aspect is that QoL impairment in the conservative cohort persisted despite the “uncomplicated” classification of the index event. This reinforces the notion that radiologic severity alone may not reflect patient-experienced disease burden. In addition, recurrence—while important—may be an incomplete endpoint. Even in the absence of repeated acute attacks, patients may experience chronic or fluctuating gastrointestinal symptoms, ongoing restrictions, and heightened concern about future episodes. Therefore, QoL assessment should be considered a key complement to recurrence-based follow-up, particularly after an initial episode where future clinical trajectory is uncertain. Regarding predictors of non-acceptable QoL after conservative management, younger age emerged as an independent predictor of PASS ≥ 3.2 at 1 month in multivariable analysis. This finding is clinically plausible: younger individuals may have greater functional expectations and lower tolerance for persistent symptoms, and they may perceive greater disruption in work, physical activity, and social life. Notably, this age-related pattern was also supported by the descriptive distribution of DV-QoL values across the age spectrum (Fig. 1 ). At both 6 and 12 months, conservatively managed patients consistently exhibited higher DV-QoL scores (worse disease-related QoL) with wider dispersion and a non-linear trend, whereas surgically treated patients showed uniformly low values with minimal variability and a relatively flat trend. The persistent separation between treatment groups across the age range supports the robustness and durability of the observed QoL differences and suggests that younger patients may experience a disproportionate functional impact of post-diverticulitis symptoms and uncertainty. Overall, these findings reinforce the usefulness of early patient reported outcomes measures (PROM)-based assessment to guide individualized counseling and management decisions. From the surgical standpoint, postoperative outcomes in our cohort were favorable, with no conversions, no anastomotic leak, no mortality, and low morbidity limited to minor complications. This confirms that elective laparoscopic sigmoidectomy can be safely performed in selected patients within experienced centers. Nonetheless, evidence from randomized trials indicates that surgery is not without clinically relevant risk, including major complications in a subset of patients [ 26 – 29 ]. Therefore, shared decision-making remains essential, balancing expected QoL improvement against operative morbidity and incorporating patient priorities. Therefore, selection bias cannot be excluded, as the decision to proceed with surgery was based on physician judgment and patient preference. Importantly, however, such bias would be expected to favor the inclusion of more symptomatic or burdened patients in the surgical group, who would typically be predisposed to worse—not better—quality of life outcomes. The consistently superior QoL observed in the surgical cohort despite this potential bias may therefore reinforce the robustness of the observed association. Second, because no patient in the surgical group exceeded PASS at follow-up, complete separation prevented inclusion of treatment allocation in multivariable modeling, limiting our ability to estimate an adjusted treatment effect. Third, baseline DV-QoL referred to the month prior to the acute episode and may have been affected by recall bias. Finally, our findings are derived from a single institution and should be interpreted in relation to local pathways and surgical expertise. Despite these limitations, our data provide clinically relevant insight into a patient-centered outcome after a first episode of uncomplicated AD. They suggest that PROM-based follow-up using diverticulitis-specific instruments can identify a meaningful subgroup with persistent and unacceptable symptom burden over time. In particular, DV-QoL combined with PASS interpretation may represent a practical approach for stratifying patients early after the index episode and guiding subsequent management discussions. Importantly, these findings should not be interpreted as supporting systematic elective resection after a first uncomplicated episode; rather, they suggest that PROM-based follow-up using diverticulitis-specific tools may help identify a clinically relevant subgroup with persistent impairment in whom early elective surgery could be discussed within a personalized risk–benefit framework. Abbreviations AD: acute diverticulitis; ASCRS: American Society of Colon and Rectal Surgeons; BMI: body mass index; CCI: Charlson Comorbidity Index; DV-QoL: diverticulitis-related quality of life; ESCP: European Society of Coloproctology; ISGRC: International Study Group of Rectal Cancer; MCID: minimal clinically important difference; ORs: odd ratios; PASS: Patient Acceptable Symptom State; PROM: patient related outcomes measures; QoL: quality of life; RCS: restricted cubic spline; SD: standard deviation; WSES: World Society of Emergency Surgery. Declarations Grant support This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors Conflict of interest statement: the authors declare they have no conflicts of interest Author Contribution G.Q., L.L. contributed to study conception data interpretation, and manuscript drafting.M.B, R.M and V.T data curation. F.T, G.D, B.B. M.C., O.S. M.A. prepared Figures 1–3. A.P.T, D.D.D, C.F. and S.A supervision.All authors contributed to manuscript revision, approved the final version, and agree to be accountable for all aspects of the work. Data Availability data, analytic methods, and study materials are available upon reasonable request at [email protected] References Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology . 2019;156(5):1282–1298. Peery AF, Keku TO, Martin CF, et al. Distribution and characteristics of colonic diverticula in a United States screening population. Clin Gastroenterol Hepatol . 2016;14(7):980–985. Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol . 2013;11(12):1609–1613. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology . 2019;156(1):254–272. Simianu VV, Flum DR. Rethinking elective colectomy for diverticulitis: a strategic approach to population health. World J Gastroenterol . 2014;20(45):16609–16614. Andeweg CS, Mulder IM, Felt-Bersma RJ, et al. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg . 2013;30(4–6):278–292. Chapman J, Davies M, Wolff B, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg . 2005;242(4):576–583. Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA . 2014;311(3):287–297. Isacson D, Andreasson K, Nikberg M, et al. Long-term follow-up after acute diverticulitis: recurrence and quality of life. Int J Colorectal Dis . 2019;34(3):401–409. Tursi A, Brandimarte G, Di Mario F, et al. Symptomatic uncomplicated diverticular disease: chronic inflammation and quality of life. Int J Colorectal Dis . 2015;30(2):149–157. Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis. Gastroenterology . 2021;160(3):906–911. Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, Steele SR, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020;63(6):728–747. doi: 10.1097/DCR.0000000000001679 . PMID: 32384404. Sartelli M, Weber DG, Kluger Y, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg . 2020;15:32. Bolkenstein HE, van de Wall BJM, Consten ECJ, et al. Long-term quality of life after conservative or surgical management of recurrent diverticulitis. Br J Surg . 2019;106(5):620–630. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum . 2014;57(3):284–294. Hall J, Hardiman K, Lee S, et al. Updated guidelines for the management of diverticulitis. Dis Colon Rectum . 2020;63(6):728–747. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373 – 83. doi: 10.1016/0021-9681(87)90171-8 . PMID: 3558716. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187 – 96. doi: 10.1097/SLA.0b013e3181b13ca2 . PMID: 19638912. Kulu Y, Ulrich A, Bruckner T, Contin P, Welsch T, Rahbari NN, Büchler MW, Weitz J; International Study Group of Rectal Cancer. Validation of the International Study Group of Rectal Cancer definition and severity grading of anastomotic leakage. Surgery. 2013;153(6):753–61. doi: 10.1016/j.surg.2013.02.007. Epub 2013 Apr 25. PMID: 23623834. Spiegel BM, Reid MW, Bolus R, Whitman CB, Talley J, Dea S, Shahedi K, Karsan H, Teal C, Melmed GY, Cohen E, Fuller G, Yen L, Hodgkins P, Erder MH. Development and validation of a disease-targeted quality of life instrument for chronic diverticular disease: the DV-QOL. Qual Life Res. 2015;24(1):163–79. doi: 10.1007/s11136-014-0753-1 . Epub 2014 Jul 25. PMID: 25059533. Barzi KV, Galli R, Denhaerynck K, Rosenberg R, von Strauss Und Torney M. Quality of life with diverticular disease: translation and validation of the German version of the diverticulitis quality of life questionnaire (DV-QOL). Tech Coloproctol. 2024;28(1):98. doi: 10.1007/s10151-024-02982-8 . PMID: 39138701. Dalby HR, Emmertsen KJ. Quality of life in diverticular disease: translation and validation of the Danish version of the diverticulitis quality of life instrument (DV-QOL). Int J Colorectal Dis. 2025;40(1):117. doi: 10.1007/s00384-025-04911-z . PMID: 40369270; PMCID: PMC12078394. Khor S, Flum DR, Strate LL, Hantouli MN, Harris HM, Lavallee DC, Spiegel BM, Davidson GH. Establishing Clinically Significant Patient-reported Outcomes for Diverticular Disease. J Surg Res. 2021;264:20–29. doi: 10.1016/j.jss.2021.01.045 . Epub 2021 Mar 18. PMID: 33744774; PMCID: PMC9011199. Costi R, Amato A, Annicchiarico A, Montali F; TabooSurvey Group; Binda GA. Acute diverticulitis management: evolving trends among Italian surgeons. A survey of the Italian Society of Colorectal Surgery (SICCR). Updates Surg. 2024;76(5):1745–1760. doi: 10.1007/s13304-024-01927-y . Epub 2024 Jul 23. PMID: 39044095; PMCID: PMC11455713. Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis. 2020;22 Suppl 2:5–28. doi: 10.1111/codi.15140 . Epub 2020 Jul 7. PMID: 32638537. Santos A, Mentula P, Pinta T, Ismail S, Rautio T, Juusela R, Lähdesmäki A, Scheinin T, Sallinen V. 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. 2021;156(2):129–136. doi: 10.1001/jamasurg.2020.5151 . PMID: 33206182; PMCID: PMC7675217. Santos A, Mentula P, Pinta T, Ismail S, Rautio T, Juusela R, Lähdesmäki A, Scheinin T, Sallinen V. Sigmoid Resection vs Conservative Treatment After Diverticulitis: Prespecified 4-Year Analysis of the LASER Randomized Clinical Trial. JAMA Surg. 2025;160(6):615–622. doi: 10.1001/jamasurg.2025.0572. PMID: 40202724; PMCID: PMC11983291. van de Wall BJM, Stam MAW, Draaisma WA, Stellato R, Bemelman WA, Boermeester MA, Broeders IAMJ, Belgers EJ, Toorenvliet BR, Prins HA, Consten ECJ; DIRECT trial collaborators. Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2017;2(1):13–22. doi: 10.1016/S2468-1253(16)30109-1 . Epub 2016 Oct 19. PMID: 28404008. Bolkenstein HE, Consten ECJ, van der Palen J, van de Wall BJM, Broeders IAMJ, Bemelman WA, Lange JF, Boermeester MA, Draaisma WA; Dutch Diverticular Disease (3D) Collaborative Study Group. Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial). Ann Surg. 2019;269(4):612–620. doi: 10.1097/SLA.0000000000003033 . PMID: 30247329. E Eypasch, J I Williams, S Wood-Dauphinee, B M Ure, C Schmulling, E Neugebauer, H Troidl, Gastrointestinal Quality of Life Index: Development, validation and application of a new instrument, British Journal of Surgery , Volume 82, Issue 2, February 1995, Pages 216–222 Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–83. Badia X, Schiaffino A, Alonso J, Herdman M (1998) Using the EuroQol 5-D in the Catalan general population: feasibility and construct validity. Qual Life Res 7:311–322 Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviews received at journal 28 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 20 Apr, 2026 Editor assigned by journal 16 Apr, 2026 Submission checks completed at journal 03 Apr, 2026 First submitted to journal 02 Apr, 2026 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 Our Team In Review Editorial Policies Advisory Board 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-9303452","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":629671840,"identity":"e54bda27-2663-4a48-bddd-ff786c3b0a4a","order_by":0,"name":"Giuseppe 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Roma","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Chiara","lastName":"Blasi","suffix":""},{"id":629671852,"identity":"24f97065-e5bd-466e-8ef9-305d551c1422","order_by":11,"name":"Matteo Aulicino","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Matteo","middleName":"","lastName":"Aulicino","suffix":""},{"id":629671853,"identity":"38484817-60ba-4c8c-a5b8-d15ebe33fd7d","order_by":12,"name":"Claudio Fiorillo","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Claudio","middleName":"","lastName":"Fiorillo","suffix":""},{"id":629671854,"identity":"c1c6a373-53bf-40ae-bcb6-cab112b3c87d","order_by":13,"name":"Sergio Alfieri","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Alfieri","suffix":""},{"id":629671855,"identity":"b1b7932f-165b-46e3-ad6a-d10175f95c1b","order_by":14,"name":"Roberta Menghi","email":"","orcid":"","institution":"Agostino Gemelli University Polyclinic","correspondingAuthor":false,"prefix":"","firstName":"Roberta","middleName":"","lastName":"Menghi","suffix":""}],"badges":[],"createdAt":"2026-04-02 12:55:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9303452/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9303452/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108072478,"identity":"2f611a7c-efaf-457f-bb72-a81828c3f563","added_by":"auto","created_at":"2026-04-29 06:13:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4140984,"visible":true,"origin":"","legend":"\u003cp\u003eAdjusted Quality of Life (QoL) scores at 6 (A) and 12 (B) months, plotted against patient age for operated (green) and non‑operated (red) individuals. Solid lines represent cubic spline models illustrating the age–QoL relationship within each group. (A): across the entire age range, operated patients exhibit significantly better QoL scores compared with non‑operated patients, with the between‑group difference being most pronounced among younger individuals (\u0026lt;40 years); (B): across the entire age range, operated patients exhibit significantly higher QoL scores compared with non‑operated patients, with the between‑group difference being most pronounced among younger individuals (\u0026lt;40 years), and for patients over 80 years.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9303452/v1/4a544778e45458ec94d8a0d1.png"},{"id":108181767,"identity":"82bc91ec-1faa-437d-a8c5-297b6462cccd","added_by":"auto","created_at":"2026-04-30 08:58:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2818167,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9303452/v1/02965fc1-89f8-47ba-bec5-6c5b33a2cadf.pdf"},{"id":108072479,"identity":"3f04fa60-8007-4974-bdb3-0b4c9f755921","added_by":"auto","created_at":"2026-04-29 06:13:14","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":291664,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-9303452/v1/1b1d7b6601c0aac5d64698d1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality of life after conservative versus elective surgical management of first-episode uncomplicated diverticulitis: a single-center prospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiverticulosis is an asymptomatic clinical condition affecting approximately 50% of individuals over the age of 60 in the United States [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to recent studies, about 5% of patients with diverticulosis will develop acute diverticulitis (AD) over time, defined as an inflammatory process of the colon resulting from inflammation of diverticula with or without associated complications [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This condition accounts for nearly 300,000 hospital admissions annually, with an estimated economic burden of approximately 9\u0026nbsp;billion dollars on the national healthcare system [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. From a clinical standpoint, AD can be categorized into uncomplicated and complicated forms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The uncomplicated form is characterized by acute inflammation of the colonic wall and pericolic fat, in the absence of radiological or clinical signs of abscess, perforation, fistula, or stricture. In contrast, the complicated form refers to diverticular inflammation associated with one or more complications, including pericolic abscess, perforation, fistula formation, stricture, or diverticular bleeding.\u003c/p\u003e \u003cp\u003eThe uncomplicated form of AD accounts for approximately 75\u0026ndash;85% of all cases of diverticulitis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In accordance with the most recent international guidelines [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the management of uncomplicated AD is primarily conservative, consisting of bowel rest and intravenous fluid therapy, with or without antibiotic treatment depending on the patient\u0026rsquo;s general clinical condition and comorbidities. However, although most patients experiencing a first episode of uncomplicated AD do not develop further episodes, approximately 8% have a risk of recurrence within one year, 19% experience a second recurrence, and 24% will have an additional episode after the third recurrence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This evidence continues to fuel the debate in the literature regarding the optimal management strategy after an episode of uncomplicated AD, by evaluating the potential benefits of elective surgical treatment following the resolution of the first episode of acute uncomplicated AD. Previous recommendations supported elective surgical resection only after multiple episodes of AD or in cases of acute inflammatory diverticular disease occurring at a young age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, more recent guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the World Society of Emergency Surgery (WSES) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] advocate for a case-by-case approach, emphasizing an individualized risk\u0026ndash;benefit evaluation when considering long-term management options\u0026mdash;whether clinical surveillance or elective surgical intervention\u0026mdash;after a first episode of uncomplicated AD. In this context, the assessment of quality of life (QoL) is progressively gaining a predominant role, representing a key element in defining the overall impact of the disease on the patient\u0026rsquo;s daily life and serving as an essential tool to determine the most appropriate management strategy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on these premises, the aim of this prospective study is to evaluate the QoL of patients following a first episode of uncomplicated AD treated conservatively, and subsequently managed either with clinical follow-up or elective surgical resection, in order to determine the most appropriate therapeutic strategy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data collection\u003c/h2\u003e \u003cp\u003eThis was a single-center, prospective, longitudinal, observational study conducted at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS of Rome between January 2021 and December 2023. The study was approved by the Institutional Ethics Committee (ID: 4522 Prot N. 0030679/21) and carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eOnly patients aged 18 years or older who admitted to the Emergency Department or the Digestive Surgery Unit of the Fondazione Policlinico Gemelli IRCCS with a clinical and radiological diagnosis of a first episode of uncomplicated AD were prospectively enrolled. Exclusion criteria were previous history of emergency surgery, previous abdominal operations, prior episodes of acute diverticulitis, and/or diagnosis of inflammatory bowel disease.\u003c/p\u003e \u003cp\u003eAD was graded according to the modified Hinchey classification [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Accordingly, only patients with a grade 0 and 1a (corresponding to uncomplicated AD) were enrolled in the study. All recruited patients underwent conservative treatment according to the current guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] until complete resolution of the clinical condition. After resolution of the index episode, patients entered routine post-diverticulitis management and were classified according to the strategy actually undertaken: clinical follow-up or elective sigmoidectomy. Treatment allocation was not protocolized and was not randomized. The decision to proceed with surgery was made within routine clinical practice by the treating surgical team, based on an individualized assessment that included patient preference and physician judgement. All patients considered for surgery underwent standard preoperative counselling and provided written informed consent for the surgical procedure.\u003c/p\u003e \u003cp\u003eThe following clinic-demographic characteristics were prospectively collected: age, sex, body mass index (BMI), smoking status, and comorbidities (also stratified for Charlson Comorbidity Index (CCI) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]). For the surgery group, additional perioperative variables were retrieved, including surgical approach (open or laparoscopic), operative time, need for ostomy, postoperative complications (including anastomotic leakage), postoperative mortality, and length of hospital stay. Post-operative complications were graded according to the Clavien-Dindo classification [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], while post-operative mortality was defined as any death occurring during the hospitalization. Anastomotic leakage was defined and classified according to the International Study Group of Rectal Cancer (ISGRC) classification [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of the study was to assess and compare QoL between patients who underwent clinical follow up (non-surgery group) and those who underwent elective laparoscopic sigmoidectomy (surgery group) after a first episode of uncomplicated AD (Hinchey 0-1a) managed conservatively.\u003c/p\u003e\n\u003ch3\u003eQuality of Life (QoL) assessment\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eThe Diverticulitis Quality of Life (DV-QOL) questionnaire\u003c/h2\u003e \u003cp\u003eThe DV-QOL (Diverticulitis Quality of Life) instrument is a disease-specific tool designed to assess the impact of AD on patients\u0026rsquo; QoL. It includes 17 items distributed across four domains: physical symptoms (5 items), concerns (3 items), feelings (4 items), and behavioural changes (5 items) [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For the non-surgery group, DV-QoL was collected at 1, 6, and 12 months after the index diverticulitis episode. For the surgery-group, DV-QoL was collected at 1, 6, and 12 months after elective sigmoidectomy. Therefore, follow-up assessments were anchored to different post-episode milestones across groups rather than to a common time origin, and comparisons should be interpreted as reflecting QoL after the management strategy actually undertaken rather than strictly time-matched outcomes after the index episode. This reflects real-world decision-based outcomes rather than strictly time-aligned comparisons. In order to assess the baseline gastrointestinal status before the first episode of AD, all patients were also asked to complete the DV-QoL questionnaire referring to one month before their first episode.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eScoring\u003c/h3\u003e\n\u003cp\u003eEach domain score is derived by converting the sum of item responses into a 0\u0026ndash;10 normalized scale, where lower values reflect better quality of life. The overall DV-QOL score is calculated summarizing the four domain scores, with each domain contributing equally, as described by Khor et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A Patient Acceptable Symptom State (PASS) threshold of 3.2 has been established: scores\u0026thinsp;\u0026lt;\u0026thinsp;3.2 correspond to an acceptable symptom burden, whereas scores\u0026thinsp;\u0026ge;\u0026thinsp;3.2 indicate symptom levels associated with a clinically relevant reduction in QoL [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical and non-surgical treatments\u003c/h2\u003e \u003cp\u003eAll patients included in the study underwent conservative management consisting of fasting, parenteral nutrition, and intravenous or oral antibiotic therapy according to clinical conditions and in accordance with current guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], until resolution of the clinical picture. During this period, a gradual reintroduction of oral feeding was undertaken, with discharge on a full diet once clinical resolution was achieved. Per protocol, at discharge, all patients were prescribed a standard therapy consisting of oral neomycin and probiotics, to be administered in one-week cycles per month, regardless of any recurrence of symptoms, together with a disease-specific diet for diverticular disease.\u003c/p\u003e \u003cp\u003ePatients in the non-surgical group underwent clinical follow-up, while patients in the surgical group were electively scheduled for laparoscopic sigmoidectomy. The procedure followed the standard steps of sigmoidectomy, including isolation and division of the sigmoid vessels, distal resection at the rectosigmoid junction using a triple-row linear stapler, proximal transection at the descending colon\u0026ndash;sigmoid junction, and end-to-end colorectal anastomosis using a triple-row circular stapler. In all cases, a hydro-pneumatic leak test of the anastomosis was performed, and the creation of a protective ileostomy was left to the discretion of the operating surgeon or in case of positive hydro-pneumatic leak test.\u003c/p\u003e \u003cp\u003ePostoperatively, adequate analgesic therapy was administered throughout the hospital stay, along with supportive intravenous fluid therapy for the first 12 hours. Patients resumed a liquid diet 24 hours after surgery, progressing to regular oral intake according to the clinical conditions. Laboratory tests, including blood chemistry and complete blood count, were performed on postoperative days 1, 3, and 5. Discharge occurred upon restoration of regular oral intake and bowel function (passage of gas and/or stool), in the absence of fever or abnormalities in laboratory findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous data were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u0026plusmn;\u0026thinsp;SD), while categorical data as number and percentages. Univariate analysis was performed with Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e tests, Mann-Whitney \u003cem\u003eU\u003c/em\u003e tests, Fisher\u0026rsquo;s tests and χ\u003csup\u003e2\u003c/sup\u003e test. For all analyses, a p value \u0026le; 0.05 was considered as statistically significant. Post-hoc statistical power was calculated using the observed effect sizes derived from paired mean differences (Cohen\u0026rsquo;s d) for the primary endpoint. Power estimates were obtained using standard analytical methods under α\u0026thinsp;=\u0026thinsp;0.05 and number of patients involved.\u003c/p\u003e \u003cp\u003eTo explore potential non-linear associations between age and QoL in relation to study outcomes, QoL was modeled using restricted cubic splines. Expected QoL values were derived from the beta coefficients of multivariate linear regression models and plotted against age. Adjusted predicted QoL at 6 and 12 months was estimated from model-based predictions and displayed according to operative intent (resection vs clinical follow-up). A restricted cubic spline (RCS) curve was fitted to describe this relationship, using age as a continuous predictor and adjusted predicted QoL as the outcome. This non-parametric approach was selected to provide a flexible representation of the association without imposing a predefined parametric form. Knots were placed at the 25th, 50th, and 75th percentiles of the age distribution, following standard recommendations for spline modeling. These graphical analyses were intended as descriptive tools to aid interpretation and were not used for inferential testing or hypothesis evaluation.\u003c/p\u003e \u003cp\u003eTo identify independent predictors of poor quality of life (DV-QoL\u0026thinsp;\u0026ge;\u0026thinsp;3.2), we included in a logistic regression model all variables that were significant in the univariate analysis. Since all patients who underwent surgical resection achieved a satisfactory QoL outcome, we performed a sensitivity analysis restricted to patients managed conservatively. Results of the logistic regression analysis are reported as odds ratios (ORs) with 95% confidence intervals.\u003c/p\u003e \u003cp\u003eAll tests were performed using SPSS version 25 for Windows (SPSS Inc., Chicago, IL, United States).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDemographical and clinical characteristic of the population\u003c/h2\u003e \u003cp\u003eA total of 137 patients were enrolled in the study: 96 (70%) underwent clinical follow-up after the first episode of uncomplicated AD and constituted the non-surgery group, while 41 (30%) underwent surgery after the conservative treatment and constituted the surgery cohort (\u003cb\u003eFigure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e). Baseline demographic and clinical characteristics of the study population are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No statistically significant differences were detected between the two study cohorts in terms of sex, age and BMI. Similarly, the two study cohorts were comparable for major comorbidities, expect for pulmonary diseases, more frequently encountered in the surgery cohort (3 -7.3%) as compared to the non-surgery group (1\u0026ndash;1%) (p\u0026thinsp;=\u0026thinsp;0.05). The distribution of Hinchey grades at presentation was comparable between groups, with the majority of patients classified as Hinchey 1a (73\u0026ndash;76% and 31\u0026ndash;75.6% in the non-surgery and surgery groups, respectively; p\u0026thinsp;=\u0026thinsp;0.95).\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\u003eDemographical and clinical characteristics of the study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePopulation (n\u0026thinsp;=\u0026thinsp;137)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-surgery (n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgery (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (43.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years, mean\u003c/b\u003e\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI, mean\u003c/b\u003e\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.5\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.5\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e+\u003c/span\u003e\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiovascular comorbidities, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary comorbidities, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharlson Comorbidity Index\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003emean\u003c/b\u003e\u0026thinsp;\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.63\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.73\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.39\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoker or ex-smoker, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHinchey grade, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1a\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (75.6)\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 \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSurgery group and post-operative outcome\u003c/h2\u003e \u003cp\u003eIntraoperative features and postoperative outcomes of the surgical group are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Surgery was performed after a mean time of 3.1\u0026thinsp;+\u0026thinsp;1.1 months after the first episode of AD. No AD recurrence was documented before surgery. No intraoperative conversions were recorded. An ostomy was required in one patient (2.4%) for a positive hydro-pneumatic leak test. Postoperative morbidity was low, with 4 patients (9.7%) experiencing Clavien\u0026ndash;Dindo grade I\u0026ndash;II complications, while no major adverse events (grade III\u0026ndash;IV) were observed in any case. No anastomotic leakage or in-hospital mortality occurred. Incisional hernia was reported in 2 patients (4.9%). The mean length of hospital stay was 6 (\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2) days.\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 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative and surgical outcomes of the surgery group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery group (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIntra-operative outcomes\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion rate, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOstomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-operative outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eI-II\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIII-IV\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisional hernia, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay, days, mean\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2\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 \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNon-surgery group\u003c/h2\u003e \u003cp\u003eOf the 96 patients managed conservatively,14 patients (14.6%) experienced AD recurrence after a mean time of 9\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.2 months after the first AD episode. Among these, 6 (42.8%) patients presented a Hichey grade 0-1a, 6 (42.8%) a grade 1b, and 2 (14.4%) and Hinchey 4 AD that required emergency surgical intervention with colostomy formation. The remaining recurrences were managed conservatively without the need for urgent surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQoL comparison between surgery and no-surgery group\u003c/h2\u003e \u003cp\u003eDV-QoL scores, at one month before the AD episode (baseline measure), were comparable between the non-surgery and surgery cohorts, with a value of 0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 and 0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33, respectively (p\u0026thinsp;=\u0026thinsp;0.14). Conversely, DV-QoL questionnaire scores were significantly lower in patients undergoing surgery compared with those managed only conservatively at all evaluated follow-up time points (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). At 1 month, the non-surgery group reported a significantly higher mean DV-QoL score compared with the surgical group (2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 vs 0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a worse QoL. Similarly, at 6 months, DV-QoL scores remained significantly higher in the non-surgery group than in the surgery cohort (2.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24 vs 0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This difference persisted at 12 months, with the non-surgery patients reporting worse DV-QoL scores compared with those who underwent elective surgery (1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07 vs 0.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\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 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of DV-QoL questionnaire scores at 1-, 6-, and 12-months between surgery and non-surgery groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-surgery group (n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery group (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffect size (Cohen\u0026rsquo;s d)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBaseline, mean\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1-month, mean\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e6-months, mean\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e12-months, mean\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.09\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\u003eLarge effect sizes were observed at all time points (Cohen\u0026rsquo;s d\u0026thinsp;\u0026gt;\u0026thinsp;1.0), indicating a sustained benefit of surgical treatment on disease-related QoL over time.\u003c/p\u003e \u003cp\u003eOverall, the analysis of DV-QoL subdomains showed a robust and sustained advantage of surgical treatment over conservative management at all the follow-up time points, with statistically significant differences consistently observed across every domain and individual questionnaire item (\u003cb\u003eTable \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e).\u003c/p\u003e \u003cp\u003ePatients were, thus, categorized according to the PASS threshold (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). At 1-month, a DV-QoL questionnaire score\u0026thinsp;\u0026gt;\u0026thinsp;3.2 was documented in 32 (33.3%) patients of the non-surgery cohort as compared to none in the surgery group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This statistical difference was furthermore confirmed at the 6-month (27 patients (28.1%) and 0 patients presenting a DVL-QoL score\u0026thinsp;\u0026gt;\u0026thinsp;3.2 in the non-surgery and surgery cohorts, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 12-month (25 patients (26%) and 0 presenting a DVL-QoL score\u0026thinsp;\u0026gt;\u0026thinsp;3.2 in the non-surgery and surgery cohorts, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0001) analyses.\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 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQoL comparison between non-surgery and surgery treatments according to the DV-QoL questionnaire PASS threshold\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-surgery (n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDV-QoL score\u0026thinsp;\u0026le;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\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\u003eDV-QoL score\u0026thinsp;\u0026gt;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 months follow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDV-QoL score\u0026thinsp;\u0026le;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\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\u003eDV-QoL score\u0026thinsp;\u0026gt;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12 months follow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDV-QoL score\u0026thinsp;\u0026le;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\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\u003eDV-QoL score\u0026thinsp;\u0026gt;\u0026thinsp;3.2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\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 \u003cem\u003eMultivariate analysis of prognostic factors for PASS threshold\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;\u003cem\u003e3.2 in the non-surgery group\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA multivariable analysis was performed to identify factors associated with unacceptable QoL (PASS\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3.2) in conservatively managed patients. \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of factors associated with non-acceptable DV-QoL (\u0026ge;\u0026thinsp;3.2) in the non-surgery 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1-month PASS threshold\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate analysis \u003c/p\u003e \u003cp\u003eodds ratio [95% Confidence Interval]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3.2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3.2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003cp\u003e[0.11\u0026ndash;0.71]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003cp\u003e[0.22\u0026ndash;3.12]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHinchey grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c7\" namest=\"c5\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6-months PASS threshold\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMultivariate analysis \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eodds ratio [95% Confidence Interval]\u003c/b\u003e\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\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;3.2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;69)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHinchey grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\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\u003e1 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e12-months PASS threshold\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMultivariate analysis \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eodds ratio [95% Confidence Interval]\u003c/b\u003e\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\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;3.2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;71)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHinchey grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (84)\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\u003eAt 1-month of follow-up, unacceptable DV-QoL (PASS\u0026thinsp;\u0026ge;\u0026thinsp;3.2) was observed in 32 patients (23.4%). Univariate analysis showed that only younger age (p\u0026thinsp;=\u0026thinsp;0.002) and a CCI\u0026thinsp;\u0026lt;\u0026thinsp;1 (p\u0026thinsp;=\u0026thinsp;0.01) were significantly associated to a worse QoL. At the multivariable analysis, only age remained an independent predictor of unacceptable quality of life (OR 0.28, 95% CI 0.11\u0026ndash;0.71; p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003eAt 6 months, only younger age was significantly associated to a PASS value\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3.2 (p\u0026thinsp;=\u0026thinsp;0.03) at the univariate analysis, while none of the clinico-demographic features significantly influenced QoL at the 12-month evaluation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAge-related distribution of DV-QoL scores (\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Scatter plots with smoothing curves were used to descriptively assess the relationship between age and DV-QoL scores at 6 and 12 months according to treatment strategy. Across the entire age range, patients managed conservatively consistently exhibited higher DV-QoL scores compared with those undergoing elective surgery, indicating worse disease-related QoL. In the non-surgical group, DV-QoL scores showed greater dispersion and a non-linear trend across age, with persistently elevated values at both younger and older ages. Conversely, surgically treated patients demonstrated uniformly lower DV-QoL scores with minimal variability and a relatively flat trend across age. This visual separation between groups persisted at both 6- and 12-month follow-up, supporting the robustness and durability of the observed differences in QoL.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective longitudinal study, we investigated diverticulitis-specific QoL after a first episode of uncomplicated AD treated conservatively, comparing subsequent clinical surveillance versus elective laparoscopic sigmoid resection. The principal finding is that elective surgery was associated with a marked and sustained benefit in disease-related QoL: surgically treated patients exhibited near-zero DV-QoL scores at 1, 6, and 12 months, and none exceeded the PASS threshold across follow-up. Conversely, patients managed conservatively reported persistently higher DV-QoL values, with approximately one-third experiencing a non-acceptable symptom state at 1 month and roughly one-quarter still above PASS at 12 months. Overall, these results suggest that, even after a first uncomplicated episode, a clinically relevant subgroup experiences prolonged impairment that is not adequately captured by traditional endpoints such as radiologic resolution or recurrence alone.\u003c/p\u003e \u003cp\u003eOver recent years, international recommendations have progressively moved away from elective resection based solely on the number of acute episodes, advocating instead for individualized decision-making after recovery from uncomplicated AD [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This approach is reflected in the European Society of Coloproctology (ESCP) guidelines, which emphasize patient-centered evaluation\u0026mdash;including symptom burden and QoL\u0026mdash;when considering elective surgery for diverticular disease [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this framework, our findings provide evidence that the impact of uncomplicated diverticulitis may extend beyond the acute inflammatory event itself, resulting in persistent symptoms, concerns, and behavioral limitations over months. This perspective supports structured follow-up strategies aimed at identifying patients who do not return to an acceptable health state despite conservative management.\u003c/p\u003e \u003cp\u003eOur results are consistent in direction with randomized evidence comparing elective sigmoid resection and conservative management for diverticular disease, where surgery has been associated with improved QoL. The LASER randomized clinical trial reported superior QoL outcomes with elective laparoscopic sigmoid resection compared with conservative treatment in patients with recurrent, complicated, or persistent painful diverticulitis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This advantage was maintained at 2-year follow-up and was accompanied by reduced recurrence rates, reinforcing the durability of the surgical benefit [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Similarly, the DIRECT multicenter randomized trial demonstrated that elective sigmoidectomy improved QoL compared with conservative management in patients with recurrent diverticulitis or ongoing complaints after an episode of diverticulitis, with long-term follow-up supporting sustained benefits in patient-reported outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Although the populations of LASER and DIRECT [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] differ from ours\u0026mdash;primarily including recurrent or persistent symptomatic disease rather than a \u0026ldquo;first uncomplicated episode\u0026rdquo;\u0026mdash;their findings support the concept that elective resection may yield meaningful patient-centered benefits when diverticular disease has a significant impact on daily life. Our study extends this paradigm earlier along the disease timeline, indicating that relevant QoL impairment can occur even after the first uncomplicated episode in a sizeable proportion of patients.\u003c/p\u003e \u003cp\u003eA major strength of our study compared to much of the existing literature is the use of the DV-QoL questionnaire, a validated diverticulitis-specific patient-reported outcome measure designed to capture domains that are uniquely relevant to diverticular disease, including physical symptoms, concerns, emotional well-being, and behavioural changes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This is particularly relevant when interpreting the literature, as several prior surgical trials have relied primarily on generic QoL tools such as GIQLI, SF-36, and/or EQ-5D, which provide valuable global assessment but may be less sensitive to disease-specific limitations and coping behaviours typical of diverticulitis [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In contrast, DV-QoL provides a more granular assessment of diverticulitis-related impairment and offers an additional advantage: clinically interpretable thresholds. Khor et al. established the PASS threshold (\u0026ge;\u0026thinsp;3.2) and minimal clinically important difference (MCID) for DV-QoL, allowing meaningful translation of PROM values into patient-acceptable versus non-acceptable symptom states [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Within this conceptual framework, our PASS-based analysis revealed that a relevant subgroup of conservatively managed patients remained in a non-acceptable symptom state even at 12 months, highlighting a \u0026ldquo;hidden burden\u0026rdquo; that might be underestimated when focusing only on recurrence or generic QoL scores.\u003c/p\u003e \u003cp\u003eImportantly, the benefit of surgery in our cohort was not limited to DV-QoL total score but was consistently observed across DV-QoL domains, suggesting a multidimensional effect of elective resection. While symptom control is likely the main driver, the sustained differences in concerns, emotional well-being, and behavioural changes suggest that surgery may mitigate the broader psychosocial burden of diverticulitis, including fear of recurrence, persistent dietary restrictions, and social or occupational limitations. This is consistent with the modern patient-centered perspective of diverticular disease, in which the goal is not only preventing acute inflammatory relapses but also restoring long-term daily functioning and well-being.\u003c/p\u003e \u003cp\u003eAnother clinically relevant aspect is that QoL impairment in the conservative cohort persisted despite the \u0026ldquo;uncomplicated\u0026rdquo; classification of the index event. This reinforces the notion that radiologic severity alone may not reflect patient-experienced disease burden. In addition, recurrence\u0026mdash;while important\u0026mdash;may be an incomplete endpoint. Even in the absence of repeated acute attacks, patients may experience chronic or fluctuating gastrointestinal symptoms, ongoing restrictions, and heightened concern about future episodes. Therefore, QoL assessment should be considered a key complement to recurrence-based follow-up, particularly after an initial episode where future clinical trajectory is uncertain.\u003c/p\u003e \u003cp\u003eRegarding predictors of non-acceptable QoL after conservative management, younger age emerged as an independent predictor of PASS\u0026thinsp;\u0026ge;\u0026thinsp;3.2 at 1 month in multivariable analysis. This finding is clinically plausible: younger individuals may have greater functional expectations and lower tolerance for persistent symptoms, and they may perceive greater disruption in work, physical activity, and social life. Notably, this age-related pattern was also supported by the descriptive distribution of DV-QoL values across the age spectrum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At both 6 and 12 months, conservatively managed patients consistently exhibited higher DV-QoL scores (worse disease-related QoL) with wider dispersion and a non-linear trend, whereas surgically treated patients showed uniformly low values with minimal variability and a relatively flat trend. The persistent separation between treatment groups across the age range supports the robustness and durability of the observed QoL differences and suggests that younger patients may experience a disproportionate functional impact of post-diverticulitis symptoms and uncertainty. Overall, these findings reinforce the usefulness of early patient reported outcomes measures (PROM)-based assessment to guide individualized counseling and management decisions.\u003c/p\u003e \u003cp\u003eFrom the surgical standpoint, postoperative outcomes in our cohort were favorable, with no conversions, no anastomotic leak, no mortality, and low morbidity limited to minor complications. This confirms that elective laparoscopic sigmoidectomy can be safely performed in selected patients within experienced centers. Nonetheless, evidence from randomized trials indicates that surgery is not without clinically relevant risk, including major complications in a subset of patients [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, shared decision-making remains essential, balancing expected QoL improvement against operative morbidity and incorporating patient priorities. Therefore, selection bias cannot be excluded, as the decision to proceed with surgery was based on physician judgment and patient preference. Importantly, however, such bias would be expected to favor the inclusion of more symptomatic or burdened patients in the surgical group, who would typically be predisposed to worse\u0026mdash;not better\u0026mdash;quality of life outcomes. The consistently superior QoL observed in the surgical cohort despite this potential bias may therefore reinforce the robustness of the observed association. Second, because no patient in the surgical group exceeded PASS at follow-up, complete separation prevented inclusion of treatment allocation in multivariable modeling, limiting our ability to estimate an adjusted treatment effect. Third, baseline DV-QoL referred to the month prior to the acute episode and may have been affected by recall bias. Finally, our findings are derived from a single institution and should be interpreted in relation to local pathways and surgical expertise.\u003c/p\u003e \u003cp\u003eDespite these limitations, our data provide clinically relevant insight into a patient-centered outcome after a first episode of uncomplicated AD. They suggest that PROM-based follow-up using diverticulitis-specific instruments can identify a meaningful subgroup with persistent and unacceptable symptom burden over time. In particular, DV-QoL combined with PASS interpretation may represent a practical approach for stratifying patients early after the index episode and guiding subsequent management discussions.\u003c/p\u003e \u003cp\u003eImportantly, these findings should not be interpreted as supporting systematic elective resection after a first uncomplicated episode; rather, they suggest that PROM-based follow-up using diverticulitis-specific tools may help identify a clinically relevant subgroup with persistent impairment in whom early elective surgery could be discussed within a personalized risk\u0026ndash;benefit framework.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAD: acute diverticulitis; ASCRS: American Society of Colon and Rectal Surgeons; BMI: body mass index; CCI: Charlson Comorbidity Index; DV-QoL: diverticulitis-related quality of life; ESCP: European Society of Coloproctology; ISGRC: International Study Group of Rectal Cancer; MCID: minimal clinically important difference; ORs: odd ratios; PASS: Patient Acceptable Symptom State; PROM: patient related outcomes measures; QoL: quality of life; RCS: restricted cubic spline; SD: standard deviation; WSES: World Society of Emergency Surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eGrant support\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest statement:\u003c/strong\u003e \u003cp\u003ethe authors declare they have no conflicts of interest\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eG.Q., L.L. contributed to study conception data interpretation, and manuscript drafting.M.B, R.M and V.T data curation. F.T, G.D, B.B. M.C., O.S. M.A. prepared Figures 1\u0026ndash;3. A.P.T, D.D.D, C.F. and S.A supervision.All authors contributed to manuscript revision, approved the final version, and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003edata, analytic methods, and study materials are available upon reasonable request at [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStrate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. \u003cem\u003eGastroenterology\u003c/em\u003e. 2019;156(5):1282\u0026ndash;1298.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeery AF, Keku TO, Martin CF, et al. 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Qual Life Res 7:311\u0026ndash;322\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"diverticular disease, quality of life, DV-QoL, uncomplicated diverticular disease, elective sigmoidectomy, diverticulosis","lastPublishedDoi":"10.21203/rs.3.rs-9303452/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9303452/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOptimal long-term management after a first episode of uncomplicated acute diverticulitis (AD) remains debated. Quality of life (QoL) is increasingly recognized as a key outcome to guide individualized decision-making between clinical surveillance and elective sigmoid resection.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis single-center prospective longitudinal observational study enrolled adults with a first episode of uncomplicated AD (Hinchey 0-1a). After recovery from the index episode, patients underwent either clinical follow-up (non-surgery group) or elective laparoscopic sigmoidectomy (surgery group) according to routine clinical decision-making. Diverticulitis-specific QoL was assessed using the DV-QoL questionnaire, retrospectively referring to the month before the index episode and prospectively at 1, 6, and 12 months after post-episode management. The primary aim was to describe and compare DV-QoL trajectories between groups. A DV-QoL score\u0026thinsp;\u0026ge;\u0026thinsp;3.2 was used to define a non-acceptable symptom state (PASS threshold). Predictors of non-acceptable QoL were explored in conservatively managed patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 137 patients were included: 96(70%) in the non-surgery group and 41(30%) in the surgery group. Baseline characteristics were comparable. Pre-episode DV-QoL scores were similar between groups (0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 vs 0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33; p\u0026thinsp;=\u0026thinsp;0.14). DV-QoL total scores were significantly higher (worse QoL) in the non-surgery group at 1 month (2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70 vs 0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 6 months (2.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24 vs 0.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and 12 months (1.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07 vs 0.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Non-acceptable QoL (PASS\u0026thinsp;\u0026ge;\u0026thinsp;3.2) occurred only in the non-surgery cohort at all time points, whereas no surgical patient exceeded PASS. Younger age independently predicted non-acceptable QoL in conservatively managed patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eElective laparoscopic sigmoidectomy after a first uncomplicated AD episode was associated with sustained improvements in disease-specific QoL compared with clinical follow-up. Routine DV-QoL assessment may help identify patients at risk of persistent impairment and optimize individualized surgical decision-making.\u003c/p\u003e","manuscriptTitle":"Quality of life after conservative versus elective surgical management of first-episode uncomplicated diverticulitis: a single-center prospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 06:13:03","doi":"10.21203/rs.3.rs-9303452/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"208462492643779605047857712499785233131","date":"2026-05-12T22:38:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317811044801984353299862164893930602683","date":"2026-05-11T05:47:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T18:24:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49709486741883900140075335891096264414","date":"2026-04-23T08:05:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-20T12:56:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T21:21:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T07:14:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2026-04-02T12:47:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c5e095c7-a1dd-45d2-88ac-b499d5e6be61","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"208462492643779605047857712499785233131","date":"2026-05-12T22:38:55+00:00","index":26,"fulltext":""},{"type":"reviewerAgreed","content":"317811044801984353299862164893930602683","date":"2026-05-11T05:47:49+00:00","index":25,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T06:13:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 06:13:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9303452","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9303452","identity":"rs-9303452","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}