Surgery versus Conservative Management for Recurrent and Ongoing Left-Sided Diverticulitis (Direct Trial): An Open-Label, Multicentre, Randomised Controlled Trial

The DIRECT Trial was an open-label, randomized controlled trial conducted across 26 centers in the Netherlands that compared nonoperative management to elective anterior resection in patients with persistent or recurrent symptoms after an episode of left-sided diverticulitis. Fifty-six patients were randomized to nonoperative management, and 53 patients were randomized to operative management. On intention-to-treat analysis, quality of life measures at 6 months were significantly higher in the surgery group compared to the nonoperative group. Of the patients in the surgery group, 98% of patients had laparoscopic surgery, conversion rate to open was 6.5%, and the incidence of temporary loop ileostomy formation was 21%. Minor perioperative complications occurred in 38% of patients, major postoperative complications occurred in 28% of patients, and the incidence of anastomotic leak was 15%. Thirteen patients (23%) in the nonoperative group had persistent abdominal complaints for which they ultimately underwent elective anterior resection. This study concluded that operative management by way of elective anterior resection improves quality of life compared to nonoperative management in patients with recurrent and persistent left-sided diverticulitis.