Routine histopathological examination in patients undergoing sigmoidectomy for diverticular disease: Are we ready to avoid it?

We read with interest the article by Petrusic et al. entitled 'Is histopathological analysis necessary in patients undergoing sigmoidectomy for diverticular disease? A retrospective study' [1]. The article investigated the necessity of routine histopathological examination in elective sigmoid resection for diverticular disease. The primary endpoint of the study was the percentage of patients with unexpected abnormal histopathological findings, either malignancy or benign polyps. Of 207 patients undergoing elective sigmoidectomy with available preoperative colonoscopy within 12 months before surgery, eight (3.9%) were found with unexpected finding at histopathological examination: five (2.4%) with a hyperplastic polyp with no dysplasia, two (1.0%) with a low-grade dysplasia polyp and one case (0.5%) with a diffuse large B-cell lymphoma. The authors concluded that, due to the increase of healthcare costs, routine histopathological examination may be avoided in selected patients undergoing elective sigmoidectomy for diverticular disease, with proper preoperative evaluation. We agree with the authors that, from a population-based medicine and cost-effectiveness point of view, the routine approach is clearly not the best solution to allocate resources. So avoiding routine histopathological examination in elective sigmoidectomy for diverticular disease may be a possible proposal, in cases with proper preoperative evaluation. The authors demonstrated that in their study population there was very low risk of unexpected findings at definitive histopathological examination. However, other studies have reported different results. In a Swedish nationwide cohort study, patients with diverticular disease were shown to have a 33% increased risk of overall incident cancer compared with a general population without diverticular disease [2]. In a study on a Danish population, an increased long-term risk of several cancer types was found in patients with diverticular disease [3]. Another Danish study registered a 2.1% risk of colorectal cancer in patients with diverticular disease, increased with respect to that of the general population [4]. Finally, in a systematic review and metanalysis, a pooled prevalence of colorectal cancer of 1.9% was found in patients with diverticular disease, with a significantly higher risk in patients with complicated diverticulitis [5]. So, we can argue that the risk of finding a cancer in patients with diverticular disease is low, but not negligible. There is another important aspect that we want to point out: the medico-legal implications that may arise from avoiding histopathological examination in operations like sigmoidectomy. The authors correctly concluded that 'the omission of routine histopathological analysis remains uncommon and controversial', but we want to stress this issue, especially in countries like Italy where medico-legal problems play a significant role in routine medical practice. Apart from demonstrating the definitive diagnosis, histopathological examination can be considered as a proof of resection and this may be of value for both patients and surgeons, especially in the case of medico-legal conflicts. The theme of avoiding routine histopathological examination is not new and this practice has been proposed for operations like cholecystectomy, haemorrhoidectomy or tonsillectomy [6-8]. Authors often conclude that, even if the risk of unexpected diagnosis is low, it is not negligible and, although not cost-effective, routine histopathological examination is still needed to identify incidental findings. Moreover, in patients with diverticular disease the same symptoms sometimes may recur after the operation in such patients and questions like 'Have they not removed my sigmoid colon in the first operation?' may come to the minds of patients. This thought will not only weaken their confidence in the surgical team but also cause medico-legal problems. For these reasons, we think that sending the removed sigmoid colon specimen for histopathological examination after elective sigmoidectomy will also constitute evidence of the procedure performed during the operation and will prevent possible medico-legal issues. We congratulate the authors for the excellent results in their population, but we think that avoiding routine histopathological examination in major surgery like sigmoidectomy is not advisable and more studies are needed to confirm these results. Conceptualization: Francesco Ferrara, Nello Grassi. Investigation: Francesco Ferrara, Ina Macaione, Giuseppa Graceffa. Writing: Francesco Ferrara, Nello Grassi, Ina Macaione. Supervision: Gianni Pantuso, Nello Grassi. None. The authors declare no conflicts of interest. This article does not contain any clinical data and no humans or animals were involved for the study. This article does not contain registered data.