Keller, Deborah S.

Abstract The management of diverticular disease has undergone a major evolution over the past two decades, shifting away from episode-count triggers for surgery toward individualized strategies informed by patient-reported outcomes, recurrence risk, and high-quality randomized clinical trials. Pivotal decision analyses and randomized trials have reshaped the surgical treatment landscape, while parallel trials of antibiotic therapy have transformed the nonoperative management of uncomplicated disease. In this study, we provide a comprehensive synthesis of historical perspectives and modern evidence regarding the surgical and nonoperative management of diverticulitis, summarize key randomized trials across the disease spectrum, describe the evolution of operative techniques, and translate these findings into actionable guidance, including a patient-centered decision aid. A structured narrative review of pivotal trials, major guidelines, and multicenter randomized studies were performed, encompassing trials of antibiotic therapy for uncomplicated diverticulitis, laparoscopic lavage for perforated disease, operative strategy for complicated disease, elective resection versus conservative therapy for recurrent or persistent symptoms, and the evolution of minimally invasive and robotic surgical techniques. Trial design, eligibility, interventions, outcomes, and limitations were extracted and synthesized. The traditional “two-episode rule” has been supplanted by individualized, symptom- and quality of life (QoL)-driven decision-making. Routine antibiotic therapy for uncomplicated diverticulitis is not supported by randomized evidence and is now reserved for select patients. Laparoscopic lavage, initially promising for perforated diverticulitis, demonstrates variable outcomes and is now reserved for selected patients with Hinchey III disease; when resection is required, primary anastomosis with diverting ileostomy is increasingly favored over Hartmann's procedure because of markedly higher stoma reversal rates. Randomized trials of elective sigmoid resection show reduced recurrence and improved QoL for patients with persistent symptoms, though not universally across all patient groups, and minimally invasive-particularly robotic-surgical techniques continue to reduce perioperative morbidity. Contemporary management of diverticulitis requires individualized evaluation anchored in patient-reported outcomes, disease phenotype, comorbidity, and shared decision-making. This study synthesizes the current evidence and provides clinic-ready decision aid for patient discussions.

Abstract Background Minimally invasive colorectal surgery is characterized by significant procedural variability, a difficult learning curve, and complications that affect patient outcomes. Video-based assessment offers an opportunity to generate data-driven insights to reduce variability, optimize training, and improve surgical performance. This mixed-methods study aimed to develop and validate a video-based assessment tool for workflow analysis across minimally invasive colorectal procedures. Methods An international steering committee panel of seven members coordinated a three-round modified Delphi process. Experts in colorectal surgery and video-based assessment were invited to reach consensus (≥ 70% agreement) on the phases and steps that describe workflows across colorectal surgery procedural videos. The resulting framework informed the development of ColoWorkflow. Four independent raters then applied ColoWorkflow to a multicentre video data set of laparoscopic and robotic colorectal procedures. Applicability and inter-rater reliability were evaluated. Results Of 66 invited experts, 41 (62%) from 11 countries completed round 1, 40 (98%) completed round 2, 20 attended the final online consensus meeting, and all (40 of 40) approved the final workflow descriptors. Consensus was achieved on nine procedure-agnostic phases (port placement and abdomen exploration; vascular dissection and ligation, mesocolon/mesorectum dissection, additional lymphadenectomy; colon and/or rectum mobilization; colorectal transection; anastomosis; completion of operation; preplanned additional procedures; unplanned procedures; extracorporeal procedures) and 34 procedure-specific steps that describe colorectal surgery workflows. ColoWorkflow was developed and applied to 54 colorectal surgery videos (left and right hemicolectomies, sigmoid and rectosigmoid resections, and total proctocolectomies) from five centres in four countries. The tool demonstrated broad applicability, as all phase and step labels, except one, were represented in at least one video. Inter-rater reliability was moderate, with a mean Cohen’s κ value of 0.72 for phases and 0.67 for steps. Most discrepancies arose at phase transitions and step boundary definitions. Conclusion Based on this preliminary work, ColoWorkflow is a promising tool for workflow analysis across minimally invasive colorectal procedures. Its adoption may help standardize training, accelerate competency acquisition, and advance data-informed surgical quality improvement.

AbstractBackgroundInflammatory bowel disease (IBD) affects more than 10 million people worldwide. Men and women are equally affected by Crohn's disease (CD). It has been shown that patients with CD are at an increased risk of a colorectal cancer (CRC) diagnosis and CRC‐related mortality. During the last two decades, biological therapies have revolutionized the treatment of CD. There are no current studies investigating the prevalence of CRC in patients with CD in the era of biological therapy and the possible features of patients with CD who are at high risk of developing CRC.AimWe aim to assess the prevalence of CRC, risk factors and profile of CRC in patients with CD receiving biological treatment compared with those who are not under biological therapy and the impact of CD‐associated colorectal strictures on CRC development. The study hypothesis is that the use of biological therapy in the control of CD activity may decrease the risk of developing CRC.Study design and settingAn international, retrospective, snapshot of the prevalence of CRC in patients with CD, reported according to the SPIRIT guidelines. The study will involve centres that hold regular IBD multidisciplinary team meetings and have both IBD colorectal surgeons and gastroenterologists. Each participating centre will provide a local consultant lead and a local trainee lead. Data will be collected within a 2‐year recruitment period (January 2017–January 2019).Study populationAdult patients who presented with CD during the study period. Patients with an incidental diagnosis of CD during evaluation for CRC will be excluded.Statistical planBaseline patient characteristics will be summarized using the appropriate descriptive statistics. Univariable, multivariable and Cox regression models will be used to identify factors significantly associated with CRC. For noncontinuous variables a comparison between the subgroups will be carried out using the chi‐square test corrected by Fisher's exact test if appropriate. A p‐value of <0.05 will be considered statistically significant.Data storageData will be stored on a secured server, pin‐code protected according to the local data management agreement.