LAUSR

There are many differences between the 1999 and 2019 statements on diverticulitis, testifying to the evolution of the surgical treatment of this disorder. The 1999 consensus focuses on the overall diagnosis and treatment of diverticular disease, whereas the 2019 statement also includes significant information on the management of acute diverticulitis. The composition of the consensus conferences also greatly varies; the 1999 version included 16 international experts, all of whom were from Europe. Levels of evidence were not used nor was a Delphi analysis employed. In contrast, the EAES/SAGES conference that created the 2019 statement was an international project with a core group of 24 experts representing the EU, the US, and Canada. Supplementing this steering group of 24 experts and residents from the 2 societies were 2 project leads and 2 librarians. Grading of Recommendations Assessment, Development and Evaluation methodology was used. Levels of evidence were rated as high, moderate, low, or very low quality for each statement. The result is 54 consensus statements and 41 recommendations across 6 broad topic areas. The 2019 consensus document was derived from 1004 complete surveys and over 300 live votes at the diverticulitis consensus conference. The fact that consensus was achieved for 40 of 41 (97.6%) of recommendations with 38 of 41 (92%) agreement in this 2019 project is evidence of impressive success; the leaders and participants should be proud of this work. Practitioners and patients will clearly benefit from the clarity provided. There are both similarities and differences in the 1999 and 2019 documents. In terms of similarities, both documents note that the proximal margin of resection should be soft supple bowel without the need for microscopic margin assessment and/or resection of all diverticular disease. Both statements also state that primary anastomosis with loop ileostomy is preferable to a Hartmann’s procedure for a variety of reasons, including initial postprocedural morbidity and the likelihood and safety of subsequent stoma reversal. The most dramatic difference is the recommended role of minimally invasive approaches in the treatment of diverticulitis. The 1999 document opines upon laparoscopy versus laparotomy, while the 2019 document addresses the nuances of laparoscopic surgery including laparoscopic lavage rather than resection, representing a significant advance during the 20-year interval. In the 1999 document, two statements stand out in this regard. “In Hinchey I and II patients, the laparoscopic approach is not the first choice, but it may be justified if no gross abnormalities are found during diagnostic laparoscopy” and “There is no place for laparoscopic resections in Hinchey III and Hinchey IV patients.” We vividly recollect laparoscopic colorectal surgery between 1991 and 1998, the first years of data collection during which opinions were formed that informed the 1999 document. We did not have the technological tools nor the technical capabilities that currently exist. Thus, these statements, in the context of 1999, were appropriate. They stand in stark contrast to the 2019 publication. As an example, question Q5.2 asks “What is the role of laparoscopic resection in emergency surgery for diverticulitis?” Answer: “Laparoscopic sigmoid resection with or without stoma in the emergency setting has been shown to decrease overall complications compared to open resections.” The minimally invasive paradigm shift is also noted in the 2019 work: “When resection is indicated we recommend consideration of laparoscopic approach for perforated diverticulitis in the appropriate clinical setting.” Also, question Q6.1 asks “What is the role of laparoscopy in elective surgery for diverticulitis?” Answer: “Laparoscopy is safe in the setting of elective surgery for diverticulitis and is associated with reduced rates of morbidity and length of stay compared to open surgery.” Finally, “a laparoscopic approach is recommended in elective surgery for diverticular and Other Interventional Techniques