The Multidisciplinary Management of Acute Complicated Diverticulitis

Abstract

Background: Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions. Summary: The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed. Key Messages: Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.

Hot Topics in Surgical Management of Acute Diverticulitiss

“…Laparoscopic resection shows advantages in terms of per operatory morbidity, length of stay, lower stoma and re-operation rate, decrease of abdominal wall complications, but needs advanced technical skills and referring centers. In Hinchey III/fecal peritonitis sigmoid resection and PRA (open or laparoscopic) could be proposed in young/fit patient; in case of emergency surgery, HP (open or laparoscopic) must be considered in critically ill/unstable patient (damage control) [49].…”

Damage control surgery for the treatment of perforated acute colonic diverticulitis

“…After first diverticulitis acute attack, 20% to 30% patients go to surgery, being about half of them performed at emergency. [ 1 – 3 ] Fifteen to 40% out of these cases involve people younger than 50. [ 1 – 3 ]…”

“…[ 1 , 2 ] Approximately 10% to 25% patients affected by colonic diverticulosis are going to develop ACD in their lifetime. [ 1 – 3 ] ACD complications arise in approximately 8% to 35% patients and the most common ones are represented by phlegmon or abscess (about 70% complications), followed by perforation, peritonitis, obstruction, and fistula. [ 1 , 4 , 5 ] Peridiverticular and pericolic infections stem from a microscopic or macroscopic perforation of one or more inflamed diverticula.…”

Pseudoaneurysm of the Mesenteric Artery Status Post Drain Placement for Complicated Diverticulitis

“…Early drainage can improve a patient’s clinical course by converting an emergent surgical situation into an elective one. Percutaneous drainage also reduces septic time, stoma creation, and decreasing hospital stay [ 1 , 2 ]. Technical success is directly apparent with purulent contents and success rates upwards of 90% [ 3 ].…”