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Invited Critique
April 2013

The Risk-Benefit Ratio: Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease”

Author Affiliations

Author Affiliations: Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.

JAMA Surg. 2013;148(4):322. doi:10.1001/jamasurg.2013.1106

Van Arendonk et al1 used the Nationwide Inpatient Sample database to evaluate outcomes for colon surgery based on the disease being treated: colon cancer (CC), diverticular disease (DD), or inflammatory bowel disease (IBD). They conclude that elective resection for DD, when the analysis is adjusted for demographic and clinical characteristics, is associated with a higher morbidity and mortality rate than that seen when operating because of CC and that these data should then be used to question the advisability of offering routine elective colectomy after successful nonoperative management of acute diverticulitis. The underlying concept or assumption seems to be that many patients being offered elective resection for DD do not really need the operation, since recent data and guidelines would suggest that the course of their disease may not ultimately take them to a middle-of-the-night emergency operation for perforation that routinely involves a stoma and the subsequent operation to reestablish gastrointestinal tract continuity. The implication is that, before we offer an elective resection for DD, we should be aware that the risk of such an undertaking may be greater than we appreciate, suggesting that perhaps we should stand down, observe, treat expectantly, and not operate so frequently. I assume we are to suppose that the sequelae of DD—inflammation, distortion of tissue planes, thick mesentery, etc—make surgery riskier and that, since the natural course of the disease is such that complications may not arise after an episode or two, why operate?