Evidence-Based Management of Diverticular Disease: What’s New and What’s Missing?
David R. Flum, • Thomas E. Read
IT seems the more we learn about diverticulitis, the less we know. In this month’s Diseases of the Colon & Rectum, “The American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines for the Treatment of Left-Sided Diverticulitis1 ” details a set of recommendations based on the best available evidence for this common condition. This update from the 2014 clinical practice guidelines (CPGs) may offer some surprises to clinicians who have been caring for patients with diverticular disease their whole careers. We congratulate the CPG committee for their work and recognize that this was a herculean task. The body of evidence has grown considerably since the last CPG. After a detailed search of the literature, 662 full-length articles were reviewed and 171 graded2 and adjudicated for this update. CPG members had to balance the limitations of these studies, hardly any of which were randomized trials, against their strengths, no small feat given many used different methodologies and outcome measures to address the same topic. Most of the recommendations were based on observational data, with only 4 having a 1a recommendation (strong recommendation based on high-quality evidence). In this update, the CPG committee has highlighted both recommendations based on the best evidence, as well as the gaps in evidence that should serve as a roadmap for investigators and research funding agencies. CPGs are systematically developed statements about best practices aimed at supporting better clinical decision-making. Their goal is to promote more evidence-based care and avoid problematic variation in practice. Professional medical societies like ASCRS have embraced this potential, investing considerable time, energy, and financial resources in creating and updating them at regular intervals. Whether CPGs are used by clinicians depends on their knowledge, attitudes, and behaviors about guidelines, including concerns that CPG recommendations “don’t apply to me and my patient.3 ” The ASCRS CPG committee recognizes that “cookbook medicine” is not their goal, and the language of the CPG gives clinicians space to consider their recommendations in the context of the individual patient. Clinicians may agree or disagree with the recommendations, but the rigorous, standardized review of this evidence speaks for itself