Treatment of acute diverticulitis of the colon - what has changed over the past two decades?
DOI:
https://doi.org/10.5281/zenodo.14857983Keywords:
acute diverticulitis, surgical treatment, individualized approach, colon resection, Hartmann procedureAbstract
Introduction: Diverticular disease ranks fifth among the most significant gastrointestinal diseases worldwide. About 20-30% of those affected experience at least one episode of acute diverticulitis in their lifetime, with 25-30% requiring emergency surgery for perforation, peritonitis, or other systemic complications.
This review aims to trace the evolution in therapeutic approaches to acute diverticulitis in recent years and present the current evidencebased strategies for its treatment.
Material and methods: A literature search was performed in the PUBMED/Medline, Embase and Cochrane Library databases using the keywords "diverticulosis", "diverticular disease", and "diverticulitis".
Results: Accumulated data over the past 20 years indicate that selected patients with uncomplicated diverticulitis can be successfully treated in an outpatient setting and without antibiotic therapy. In patients with diverticulitis complicated by abscess formation, nonsurgical methods, such as antibiotic therapy and percutaneous drainage, are increasingly being used, and there are still disagreements regarding the minimum abscess size required to undertake the procedure. Regarding the surgical treatment of acute diverticulitis, there has been a trend that the approach should be individualized and risk-adapted, andthe decision to proceed with surgery and the type of surgery should be based on the presented patient's factors ( general condition, comorbidity, etc.) and the severity of acute diverticulitis.
Conclusion: New studies, especially in the long term, are needed to provide additional data and clarify the still controversial aspects ofmanaging acute diverticulitis.
References
1. Angriman I, Scarpa M, Ruffolo C, Health related quality of life after surgery for colonic diverticular disease, World J Gastroenterol 2010; 16(32): 4013-18.
2. Cirocchi R, Sapienza P, Anania G, Binda GA, et al., State-of-the-art surgery for sigmoid diverticulitis. Langenbecks Arch Surg. 2022;407(1):1-14.
3. Martin S., Stocchi L., New and emerging treatments for the prevention of recurrent diverticulitis, Clin and Exp Gastroenterol 2011:4, 203-12.
4. Stovall SL, Kaplan JA, Law JK, Flum DR, Simianu VV. Diverticulitis is a population health problem:Lessons and gaps in strategies to implement and improve contemporary care. World J Gastrointest Surg 2023;15(6): 1007-19.
5. Peery AF, Crockett SD, Murphy CC, et al, Burden and Cost of Gastrointestinal, Liver, andPancreatic Diseases in the United States: Update 2018. Gastroenterology 2019; 156: 254-72.
6. Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47: 1953-64
7. Cirocchi R, Afshar S, Di Saverio S, et al. A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine. World J Emerg Surg. 2017;12:14.
8. Beyer-Berjot L, Maggiori L, Loiseau D, et al., Emergency Surgery in Acute Diverticulitis: A Systematic Review. Dis Colon Rectum. 2020;63(3):397-405.
9. Cirocchi R, Duro F, Avenia S, et al. Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review. J Clin Med. 2023;12(17):5522.
10. Qaseem, A.; Etxeandia-Ikobaltzeta, I.; Lin, J.S.; Fitterman, N.; Shamliyan, T.; Wilt, T.J.; Clinical Guidelines Committee of theAmerican College of Physicians; Crandall, C.J.; Cooney, T.G.; Cross, J.T., Jr.; et al. Diagnosis and Management of Acute Left-SidedColonic Diverticulitis: A Clinical Guideline from the American College of Physicians. Ann. Intern. Med. 2022, 175, 399–415.
11. Kruis, W.; Germer, C.T.; Böhm, S.; Dumoulin, F.L.; Frieling, T.; Hampe, J.; Keller, J.; Kreis, M.E.; Meining, A.; Labenz, J.; et al.German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society of General and VisceralSurgery (DGAV) (AWMF-Register 021-
20). German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis,epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification. United Eur. Gastroenterol. J. 2022,10, 923–39.
12. Kruis, W.; Germer, C.T.; Böhm, S.et al. German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society of General andVisceral Surgery (DGAV) (AWMF-Register 021-20). German guideline diverticular disease/diverticulitis: Part II: Conservative,interventional and surgical management. United Eur. Gastroenterol. J. 2022, 10, 940–57.
13. Schultz, J.K.; Azhar, N.; Binda, G.A. et al. European Society of Coloproctology: Guidelines for the management of diverticular disease of the colon.Color. Dis. 2020, 22 (Suppl. 2), 5–28.
14. Sartelli, M.; Weber, D.G.; Kluger, Y.et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J.Emerg. Surg. 2020, 15, 32.
15. Hall, J.; Hardiman, K.; Lee, S. Et al, Prepared on behalf of theClinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colonand Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis. Colon Rectum 2020,63, 728–47.
16. Francis, N.K.; Sylla, P.; Abou-Khalil, M.et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: Evidence-based recommendationsfor clinical practice. Surg. Endosc. 2019, 33, 2726–41.
17. Pietrzak, A.; Bartnik, W.; Szczepkowski, M.et al, An interdisciplinary consensus ondiagnostics and treatment of colonic diverticulosis. Pol. J. Surg. 2015, 87, 203–20.
18. Binda, G.A.; Cuomo, R.; Laghi, A.; et al, Italian Society of Colon andRectal Surgery. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery(SICCR) guidelines. Tech. Coloproctol. 2015, 19, 615–26.
19. Cuomo, R.; Barbara, G.; Pace, F.et al. Italianconsensus conference for colonic diverticulosis and diverticular disease. United Eur. Gastroenterol. J. 2014, 2, 413–42.
20. Andeweg, C.S.; Mulder, I.M.; Felt-Bersma, R.J.; et al. Gastroenterologists, Radiology, Health technology Assessment and Dieticians. Guidelines ofdiagnostics and treatment of acute left-sided colonic diverticulitis. Dig. Surg. 2013, 30, 278–92.
21. Andersen, J.C.; Bundgaard, L.; Elbrønd, H.; Laurberg, S.; Walker, L.R.; Støvring, J. Danish Surgical Society. Danish nationalguidelines for treatment of diverticular disease. Dan. Med. J. 2012, 59, C4453.
22. NICE Guideline. Diverticular Disease: Diagnosis and Management. Available online: http://www.nice.org.uk/guidance/ng147.
23. Zaborowski AM, Winter DC. Evidence-based treatment strategies for acute diverticulitis. Int J Colorectal Dis. 202;36(3):467-75.
24. Stocchi L. Current indications and role of surgery in the management of sigmoid diverticulitis. World J Gastroenterol 2010; 16(7): 804-17.
25. Ambrosetti P et al,Computed tomography in acute left colonic diverticulitis.Br J Surg 1997;84(4):532–4
26. Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg. 2021;110(2):180-6
27. Chabok A, Pahlman L, Hjern F et al: Randomized clinicaltrial of antibiotics in acute uncomplicated diverticulitis. Br JSurg 2012;99(4):532–9.
28. Daniels L, Ünlü Ç, de Korte N et al: Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 2017;104(1):52–61.
29. van Dijk ST, Daniels L, Ünlü Ç et al: Longterm effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol 2018;113(7):1045–52
30. Jaung R, Nisbet S, Gosselink MP et al: Antibiotics do not reduce length of hospital stay for uncomplicated diverticulitis in a pragmatic doubleblind randomized trial. Clin Gastroenterol Hepatol 2020;19:503–10.e1
31. Jackson JD, Hammond T Systematic review: outpatientmanagement of acute uncomplicated diverticulitis. Int JColorectal Dis 2014; 29(7):775–81.
32. Biondo S et al Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenterrandomized clinical trial (DIVER Trial). Ann Surg 2014;259(1):38–44.
33. Isacson D, Thorisson A, Andreasson K et al: Outpatient,non-antibiotic management in acute uncomplicateddiverticulitis: A prospective study. Int J Colorectal Dis2015;30(9):1229–34.
34. E. Arabadzhieva, S. Bonev, A. Jonkov, D. Bulanov, V. Dimitrova, complicated colonic diverticular disease - indications and strategies for surgical treatment, scripta scientifica medica 2013, v.45, s2, 91-7.
35. Ryan OK, Ryan ÉJ, Creavin B et al. Systematic review and meta-analysis comparing primary resection and anastomosis versus Hartmann's procedure for the management of acute perforated diverticulitis with generalised peritonitis. Tech Coloproctol. 2020;24(6):527-43.
36. Lee JM et al,Hartmann’s procedure vs primary anastomosiswith diverting loop ileostomy for acute diverticulitis: nationwideanalysis of 2,729 Emergency Surgery Patients. J Am Coll Surg 2019; 229(1):48–55
37. Myers E, Hurley M, O’Sullivan GC, et al. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95(1):97–101.
38. Vennix S, Musters GD, Mulder IM, et al.; LADIES trial colloborators. Laparoscopic peritoneal lavage or sigmoidectomyfor perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet. 2015;386:1269–77.
39. Schultz JK et al Laparoscopic lavage vs primary resectionfor acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA 2015; 314(13):1364–75.
40. Angenete E et al., Laparoscopic lavage is feasible and safe forthe treatment of perforated diverticulitis with purulent peritonitis:the first results from the randomized controlled trial DILALA. AnnSurg 2016; 263(1):117–22.
41. Strate LL, Morris AM, Epidemiology, Pathophysiology, and Treatment of Diverticulitis, Gastroenterology 2019;156:1282–98.
42. Cirocchi R, Popivanov G, Konaktchieva M et al, The roleof damage control surgery in the treatment of perforated colonicdiverticulitis: a systematic review and meta-analysis. Int J Colorectal 2021; Dis 36(5):867–79
43. Parks TG. Natural history of diverticular disease of the colon: a review of 521 cases. BMJ 1969;4:639–42 44. Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006; 243: 876-83.
45. Bolkenstein HE, Consten ECJ, van der Palen J, van de Wall BJM et al, Dutch Diverticular Disease (3D) CollaborativeStudy Group. Long-term outcome of surgery versus conservativemanagement for recurrent and ongoing complaints after an episodeof diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial). Ann Surg. 2019; 269(4):612–20.
46. Santos A, Mentula P, Pinta T et al. Comparing laparoscopic elective sigmoid resection with conservative treatmentin improving quality of life of patients with diverticulitis: thelaparoscopic elective sigmoid resection following diverticulitis(LASER) randomized clinical trial. JAMA Surg 2021; 156(2):129–36.
47. Cirocchi R, Fearnhead N, Vettoretto N et al The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits:a systematic review and meta-analysis. Surgeon 2019; 17(6):360–369.
48. Curfman KR, Jones IF, Conner JR et al, Robotic colorectal surgery in the emergent diverticulitis setting: is it safe? A review of large national database. Int J Colorectal Dis. 2023;38(1):142.
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Copyright (c) 2023 Elena Arabadzhieva (Author)
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