Role of elective surgery in

acute divertiulitis

Diverticulosis: the presence of asymptomatic

diverticula within the colon in the absence of
associated inflammation
Acute diverticulitis: clinically evident macroscopic
inflammation of a diverticulum or diverticula
4% of patients with diverticulosis
15% of those patients will have complicated
disease, )abscess, perforation, fistula, colonic
obstruction or stricture(
15% to 30% will experience recurrence

 Emergency:
laparoscopic lavage (with/without
drain placement),
defunctioning stoma
Hartmanns procedure
sigmoid colectomy with primary
anastomosis either with/without
covering loop stoma

 Elective:

recurrent uncomplicted acute

diverticulitis

complicated acute divertiulitis

 In 2000 the American Society of Colon

and Rectal Surgeons:
recommended elective surgery after two
episodes of AD .
In 2006 the same group
stated that elective colonic resection
after AD should be performed on a caseby-case basis

 Elective resection for a patient with a single

episode of uncomplicated diverticulitis is not
supported
for a patient with recurrent (two or more)
episodes of diverticulitis :
a single blanket
recommendation is not appropriate and the
decision as to whether or not to offer surgery in
this group of patients should be made on an
individual patient basis
Association of Coloproctology of Great Britain and Ireland
Commissioning guide: Colonic diverticular disease 2014

 the number of episodes of recurrent

AD
no longer an indication to elective
resection
patient-related factors, not the
number of previous episode of AD,
should lead to the
elective surgical treatment

 Practice Parameters for the

Treatment of Sigmoid
Diverticulitis
Daniel Feingold, M.D. Scott R. Steele, M.D. Sang Lee, M.D. Andreas
Kaiser, M.D. Robin Boushey, M.D. W. Donald Buie, M.D. Janice Frederick
Rafferty, M.D.

Prepared by the Clinical Practice Guideline Task

Force of the American Society of Colon and
Rectal Surgeons2014

 T he decision to recommend elective

sigmoid colectomy after recovery from
uncomplicated acute diverticulitis should
be individualized.
Grade of Recommendation:
Strong recommendation based on
moderate-quality evidence,1B.

 patient-related factors:
Immunosuppressed patients and patients with chronic
renal failure or collagen-vasculardisease
effects on lifestyle(professional and personal) imposed
by recurrent attacks
chronic or lingering symptoms that may
constitutesmoldering
disease
severity of the attacks
the overall medical condition of the patient

 Elective colectomy should typically be

considered after the patient recovers
from an episode of complicated
diverticulitis.
Grade of Recommendation:
Strong recommendation based on
moderate-quality evidence, 1B.

 Neither phlegmon nor extraluminal gas

alone seen on imaging is considered
complicated disease
mesocolic abscesses of 5 cm or pelvic
abscess
)elective colectomy should typically be
advised(

stricture or fistula formation

elective or semielective resection is generally necessary
to provide symptomatic relief.

 Medically Treated Diverticular

Abscess Associated With High Risk of
Recurrence and Disease
Complications.
Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM
1Division of Colorectal Surgery, Department of
Surgery, Keck School of Medicine, University of
Southern California, Los Angeles, California
Dis. Colon Rectum
- March 1, 2016; 59 (3); 208-15

 retrospective review of all patients 210)

patients(with diverticular abscess confirmed
by CT from 2004 to 2014

185 patients successfully managed without surgery and

discharged from the hospital
recurrent diverticulitis developed in 112 (60.5%)..... average time
interval of 5.3 months.
47 patients (42%) experienced more than 1 episode.
51 patients (45.6%). Inreased modified Hinchey stage at time of
recurrence
Seventy one (63%) of 112 recurrences showed local disease
complications (recurrent
abscess, fistula, stricture, or peritonitis)
Twenty nine (26%) of 112 recurrences required an urgent operation
13 (29.2%) of 45 patients with recurrence after successful CT-guided
drainage subsequently required an urgent operation.

 Diverticular abscesses represent

complicated diverticulitis and are
associated with a high risk of recurrences
and disease complications.
Recurrences (contrary to other series)
were often more severe than the index
presentation
successful CT-guided drainage of a
diverticular abscess does not appear to
lower the risks of future recurrence or
complication rates
After initial successful nonoperative
management, patients with diverticular

patients perspective on the risk of recurrences and persistent

bowel symptoms associated with surgical or conservative
treatment

 systematic review and meta-analysis of quality

of life (QOL) and other patient-reported
outcomes (PROs) after conservative vs surgical
treatment of uncomplicated diverticulitis.
data from 21 studies that comprised 1858
patients between January 1990 through May
2014

 patients had higher QOL scores after

elective laparoscopic resection(73.4; 95%
confidence interval [CI], 65.781.1) than
conservative treatment (58.1; 95%
CI,47.269.1).
A lower proportion of patients had
gastrointestinal symptoms after
laparoscopic surgery (9%; 95% CI, 4%
14%) than conservative treatment (36%;
95% CI, 27%45%)

 Heterogeneity among the existing studies

is substantial, impeding strong
conclusions on best treatment
Elective laparoscopic surgery might have
benefits
in terms of general QoL and
gastrointestinal symptoms compared with
conservative treatment in patients with
disabling chronic complaints or recurrent
diverticulitis

 In the largest cohort of 500

laparoscopic resections for
diverticulitis,
conversion rate was 2.8%, incidence of
anastomotic
leakage was 1.4%, and overall mortality
was 0.2%.