Highly selected group of patients at this stage may be treated by conservative treatment. However, it may be associated with a significant failure rate and a careful clinical and CT monitoring is mandatory [ 20 ]. We suggest performing laparoscopic peritoneal lavage and drainage only in very selected patients with generalized peritonitis. It is not considered as the first line treatment in patients with peritonitis from acute colonic diverticulitis weak recommendation based on high-quality evidence, 2A.
A minimally invasive approach using laparoscopic peritoneal lavage and drainage has been debated in recent years as an alternative to colonic resection [ 72 ]. It can potentially avoid a stoma in patients with diffuse peritonitis. It consists of the laparoscopic aspiration of pus followed by abdominal lavage and the placement of abdominal drains, which remain for many days after the procedure.
In , a Dutch retrospective analysis of 38 patients [ 73 ] treated by laparoscopic lavage was published highlighting some doubts about this procedure to treat critically ill patients. In seven patients, this approach did not control abdominal sepsis, two patients died of multiple organ failure and five ones required further surgical interventions three Hartmann resection, one diverting stoma, and one perforation closure.
One of these died from aspiration, and the remaining four experienced prolonged and complicated hospital stay. The authors concluded that patient selection was of utmost importance and identification of an overt sigmoid perforation is of critical importance.
Initial diagnostic laparoscopy showing Hinchey III disease was followed by randomization between laparoscopic lavage and colon resection and stoma.
Morbidity and mortality after laparoscopic lavage did not differ when compared with the Hartmann procedure. Laparoscopic lavage resulted in shorter operating time, shorter time in the recovery unit, and shorter hospital stay with the avoidance of a stoma.
In this trial, laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III disease was feasible and safe in the short-term. Among patients with likely perforated diverticulitis and undergoing emergency surgery, the use of laparoscopic lavage vs. These findings do not support laparoscopic lavage for treatment of perforated diverticulitis. This showed that laparoscopic lavage was not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis [ 76 ].
After their publication, the results of the three studies were summarized in six different meta-analyses, with similar findings [ 77 , 78 , 79 , 80 , 81 , 82 ]. When compared with emergency surgery with resection, laparoscopic lavage in Hinchey III acute diverticulitis shows a comparable mortality but is associated with a failure rate with a significantly augmented need for reoperation due to the failure of the treatment and to intra-abdominal abscess formation.
Long-term results were similar, with no difference in morbidity and mortality. Several controversies remain about laparoscopic lavage and drainage. It may be an acceptable alternative in selected patients [ 83 ]; however, it cannot be considered the first line treatment in patients with diverticular peritonitis.
In clinically stable patients with no comorbidities, we suggest primary resection with anastomosis with or without a diverting stoma weak recommendation based on low-quality evidence, 2B. HP has been considered the procedure of choice in patients with generalized peritonitis and remains a safe technique for emergency colectomy in diverticular peritonitis, and is especially useful in critically ill patients and in patients with multiple comorbidities.
However, restoration of bowel continuity after a HP is associated with significant morbidity and resource utilization [ 84 ].
As a result, many of these patients do not undergo reversal surgery and remain with a permanent stoma [ 85 ]. Common use of the HP in treating diverticular perforation worldwide is confirmed by a recent Australian study analyzing administrative data of patients with acute diverticulitis admitted, from to , in eight tertiary referral centers with specialist colorectal services [ 86 ].
Another population-based retrospective cohort study using administrative discharge data, conducted in Ontario, Canada, was published in [ 87 ]. Among 18, patients hospitalized with a first episode of diverticulitis, from to , underwent emergency surgery. In recent years, some authors have reported the role of primary resection and anastomosis with or without a diverting stoma, in the treatment of acute diverticulitis, even in the presence of diffuse peritonitis [ 88 ].
The decision regarding the surgical choice in patients with diffuse peritonitis is generally left to the judgment of the surgeon, who takes into account the clinical condition and the comorbidities of the patient. Studies comparing mortality and morbidity of the HP versus primary anastomosis did not show any significant differences. However, most studies had relevant selection biases, as demonstrated by four systematic reviews [ 89 , 90 , 91 ]. Out of , patients, patients were included.
Patients undergoing a HP had more comorbidities [e. The mortality rates for the patients undergoing a HP versus primary anastomosis with diverting loop ileostomy were 7. The morbidity rates were The authors concluded that primary anastomosis with diverting loop ileostomy appears to be at least a safe alternative to the HP for select patient populations needing emergent surgical management of acute diverticulitis.
A comparison of primary resection and anastomosis with or without defunctioning stoma to the HP as the optimal operative strategy for patients presenting with Hinchey stage III—IV was published by Constantinides et al. A total of primary resection and anastomosis, primary anastomosis with defunctioning stoma, and HPs were considered in the study. The authors concluded that primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis and may represent a good compromise between postoperative adverse events, long-term quality of life, and risk of permanent stoma.
A small randomized trial of primary anastomosis with ileostomy versus a HP in patients with diffuse diverticular peritonitis was published by Oberkofler et al. Overall mortality did not differ significantly between the HP 7. Although mortality was similar in both arms, the rate of stoma reversal was significantly higher in the primary anastomosis arm.
This trial provides additional evidence in favor of primary anastomosis with diverting ileostomy over the HP in patients with diverticular peritonitis.
Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated to the HP or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. The month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with the HP Recently, a systematic review of the existing literature about surgical management of Hinchey III and IV diverticulitis was published [ 97 ]. A total of 25 studies involving patients were included in this study.
The overall mortality in patients undergoing a HP was The mortality rate in patients undergoing a primary anastomosis was lower than that in the HP group, at 8. However, meta-analysis of the RCTs did not demonstrate any difference in mortality.
Wound infection rates between the two groups were comparable. In patients with diffuse peritonitis due to perforated diverticulitis, we suggest to perform an emergency laparoscopic sigmoidectomy only if technical skills and equipment are available weak recommendation based on low-quality evidence, 2C. Laparoscopic sigmoidectomy for diverticulitis had initially been confined to the elective setting. However, in physiologically stable patients, laparoscopic sigmoidectomy may be feasible in the setting of purulent and fecal diverticular peritonitis.
In , a systematic review on laparoscopic sigmoidectomy for diverticulitis in the emergency setting was published [ 98 ]. The review included 4 case series and one cohort study total of patients out of references.
A HP was performed in 84 patients, and primary anastomosis was fashioned in 20 patients. Surgical re-intervention was necessary in 2 patients. In 20 patients operated upon without defunctioning ileostomy, no anastomotic leakage was reported.
Three patients died during the postoperative period. These guidelines are limited by the low-quality evidence that showed that emergency laparoscopic sigmoidectomy for the treatment of perforated diverticulitis with generalized peritonitis is feasible.
These studies occurred in selected patients and in experienced units and are not generalizable to all centers. High-quality prospective or randomized studies are needed to demonstrate benefits of emergency laparoscopic sigmoidectomy compared to open sigmoidectomy for perforated diverticulitis. We suggest damage control surgery DCS with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforation weak recommendation based on low-quality evidence, 2C.
A damage control surgical strategy may be useful for patients in physiological extremis from abdominal sepsis [ 99 ]. The initial surgery focuses on control of the sepsis, and a subsequent operation deals with the anatomical restoration of the gastrointestinal tract, after a period of physiological resuscitation. This strategy facilitates both the control of the severe sepsis control as well as potentially improving the rate of primary anastomosis [ ]. Generalized diverticular peritonitis is a life-threatening condition requiring prompt emergency operation.
To improve outcomes and reduce the rate of colostomy formation, a new algorithm for damage control operation, lavage, limited resection or closure of perforation, and second look surgery to restore intestinal continuity was developed in recent years [ , ].
Some patients may be physiologically deranged. These patients, who are hemodynamically unstable, are not optimal candidates for immediate complex operative interventions.
After initial surgery, which should be limited to source control, e. However, this strategy will also delay bowel anastomosis to a period of physiological stability [ ] potentially changing the intraoperative physiological milieu, potentially favoring a primary anastomosis, and avoiding the formation of a stoma altogether. In the setting of acute diverticulitis, several reports with low level of evidence were published.
In , a prospective observational study was published by Kafka-Ritsch et al. The overall mortality rate was 9. Fascial closure was achieved in all patients. Sohn et al. Despite promising experiences, little robust or large-scale data are available, and the open abdomen and damage control strategy are not without risk: for example, such procedures are associated with the formation of entero-atmospheric fistula and high costs, among other issues.
Guidelines recommend this strategy only in critically ill patients who cannot withstand major surgery. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. The WSES recommends to use an open abdomen approach in selected significantly physiologically deranged patients with ongoing sepsis [ ].
The Closed Or Open after Laparotomy COOL study constitutes a prospective RCT that will randomly allocate eligible surgical patients intraoperatively to either formal closure of the fascia or use of the open abdomen with application of with active negative peritoneal pressure therapy. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only [ ].
We suggest evaluating patient-related factors and not number of previous episodes of diverticulitis in planning elective sigmoid resection weak recommendation based on very low-quality evidence, 2D.
After an episode of ALCD treated conservatively, we suggest planning of an elective sigmoid resection in high-risk patients, such as immunocompromised patients weak recommendation based on very low-quality evidence, 2D. Recurrence of acute diverticulitis is lower than previously thought.
Historically, it has been reported that about one third of all patients with acute diverticulitis will have a recurrent attack, often within 1 year [ , ].
However, the recurrence after an uncomplicated episode of diverticulitis appears much lower: with a recent prospective study reported a recurrence of only 1. Emergency and elective colectomy rates were 0. Female gender, young age, smoking, obesity, and complicated initial disease were risk factors for readmission and emergency surgery.
The study also pointed out that some factors associated with recurrence are modifiable; weight reduction and smoking cessation can be championed. In , a systematic review of studies reviewing the diagnosis and management of chronic and recurrent diverticulitis from studies published between January to March was published [ ]. The 68 studies included were almost exclusively observational and had limited certainty of treatment effect.
The authors concluded that the indication for elective colectomy following 2 episodes of diverticulitis is no longer accepted. Indication to colectomy should be made based on consideration of the risks of recurrent diverticulitis, the morbidity of surgery, ongoing symptoms, the complexity of disease, and operative risk.
A recent open-label randomized multicenter trial DIRECT trial randomized patients from 24 teaching and two academic hospitals in the Netherlands presenting with recurrent and persisting abdominal complaints after an episode of diverticulitis to receive surgical treatment or non-operative management [ ].
However, the results of the study may be affected by the heterogeneity of patients enrolled patients with both recurrent diverticulitis and patients with persistent abdominal complaints. We suggest to choose the empirically designed antibiotic regimen on the basis of the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns strong recommendation based on moderate-quality evidence, 1B.
We suggest a 4-day period of postoperative antibiotic therapy in complicated ALCD if source control has been adequate weak recommendation based on moderate-quality evidence, 2B. Antibiotic therapy plays an important role in the management of complicated acute diverticulitis. Typically, it is an empiric antibiotic treatment.
The regimen should depend on the severity of infection, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns [ 39 ]. Several recommendations have been recently published in literature [ 39 ]. However, consideration of local epidemiological data and resistance profiles is essential for antibiotic selection. Considering intestinal microbiota of large bowel acute diverticulitis requires antibiotic coverage for Gram-positive and Gram-negative bacteria, as well as for anaerobes.
Most of the complicated acute diverticulitis is mainly a community-acquired infection. The main resistance threat in IAIs is posed by extended-spectrum beta-lactamase ESBL -producing Enterobacteriaceae , which are becoming increasingly common in community-acquired infections worldwide [ 33 ].
The most significant risk factors for ESBL-producing pathogens include prior exposure to antibiotics and comorbidities requiring concurrent antibiotic therapy [ 39 ].
Anti-ESBL-producer coverage should be warranted for patients with these risk factors. Discontinuation of antibiotic treatment should be at 4 days from source control as this has been demonstrated as non-inferior to longer therapy based on the STOP IT trial [ ].
The recent prospective trial by Sawyer et al. Acute colonic diverticulitis is a common condition affecting the adult population. Traditionally, the sigmoid colon is considered the most commonly involved part, and ARCD is much rarer [ ]. The former is usually solitary [ 29 , ], and has a low rate of complicated diverticulitis [ ]. ARCD generally occurs in middle-aged men, and its incidence does not increase with age. CT scanning appears to be the best overall imaging modality in the diagnosis of possible ARCD [ , ].
However, US is more economic than CT and poses no radiation, which may be particularly important since the patients having right-sided diverticulitis are relatively younger. US features, including diverticular wall thickening, surrounding echogenic fat, and intra-diverticular echogenic material, can provide clear information for making correct preoperative diagnosis.
However, US is operator dependent. Ambiguous US studies may be complemented with a contrast-enhanced CT [ ]. Currently, the management of ARCD is not well defined, and no unique guidelines have been proposed. As a treatment option, non-operative methods should be preferred, in cases without diffuse peritonitis although differentiating benign and malignant cases pre-operatively is often difficult [ ]. Surgical treatment is usually used in the treatment of complicated cases [ , , ].
Resection of the inflamed colon with primary anastomosis can be performed by laparoscopy in experienced centers [ ]. The sigmoid is usually the most commonly involved colonic segment, while ARCD is much rarer. An international multidisciplinary panel of experts from the World Society of Emergency Surgery WSES updated its guidelines on the management of acute left-sided colonic ALCD diverticulitis according to the most recent available literature.
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Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Diverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review. Ampicillin, 2 g IV every six hours, plus metronidazole, mg IV every six hours, plus amikacin, gentamicin, or tobramycin. Information from references 22 through Patients with a localized abscess may be candidates for CT-guided percutaneous drainage, a procedure that does not increase the risk of recurrent diverticulitis.
It should be used to stratify a patient's risk before surgery Table 5. Cloudy, purulent. Br J Surg. Risk factors for diverticulitis include use of nonsteroidal anti-inflammatory drugs, increasing age, obesity, and a sedentary lifestyle. Patients who present with symptoms consistent with recurrent diverticulitis warrant a complete evaluation.
Studies have shown recurrence rates of diverticulitis from 9 to 36 percent. In a large retrospective study involving 3, patients treated for diverticulitis with a mean follow-up of nine years, 9 percent had one recurrence and 3 percent had more than one recurrence after initial nonoperative management.
A retrospective study analyzing consecutive patients with diverticulitis found the five-year recurrence rate was 36 percent, with 3. Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, and, in persons with a body mass index of 30 kg per m 2 or higher, weight loss.
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