Seminars in Colon and Rectal Surgery 32 (2021) 100799

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Seminars in Colon and Rectal Surgery

journal homepage: www.elsevier.com/locate/yscrs

Acute diverticulitis: Surgical management

Na Eun Kim, MD, Jason F. Hall, MD, MPH*
Department of Surgery, Boston Medical Center, Moakley Building, 830 Harrison Ave., 2nd Floor, Boston, MA 02118, United States

A R T I C L E I N F O A B S T R A C T

Keywords: The management of acute diverticulitis is a constantly evolving field. Diverticular disease can range from mild
Diverticulitis abdominal pain to severe disease with perforation and sepsis. Due to this wide spectrum of presentation,
Sigmoid colectomy management must be tailored to the individual. Treatment options vary from medical management to laparo-
Laparoscopic lavage scopic lavage to colectomy to appropriately treat the patient. The surgeon is responsible in assessing the
necessity of surgery for patients who not only present acutely, but for those who have recovered and may
need planning for possible recurrences. This chapter will review the current recommendations for the surgical
management of acute diverticulitis.
© 2020 Published by Elsevier Inc.

Indications for surgical management- Decision making
Uncomplicated diverticulitis
The management of acute diverticulitis has changed significantly
over the past three decades. Surgical management of acute uncompli-
cated diverticulitis was previously advocated to prevent future compli-
cations of diverticular disease. More recent literature demonstrates
that acute uncomplicated diverticulitis confers a recurrence rate of
15 36%1 4 and the risk of recurrence increases with every episode.5
However, complications such as fistula, abscess, and free perforation
during those recurrence episodes are rare.4 The likelihood of needing
emergency surgery after an episode of uncomplicated diverticulitis is
low with 1 in 2000 patient-years of follow up.6,7 Among patients with
recurrent diverticulitis, 1.8- 7% patients underwent emergency sur-
gery.8,5 Elective surgery for the purposes of preventing a future recur-
rence requiring emergency surgery is therefore not recommended.
While performing elective surgery to reduce the risk of a compli-
cated recurrence is no longer recommended, patients with uncompli-
cated diverticular disease are at increased risk of further
recurrences.9,10,8 After two episodes of diverticulitis, the risk of sub-
sequent recurrence almost doubles.10 Continued episodes of uncom-
plicated diverticulitis and medical management may not be desirable
to patients and they may elect to have surgery. Patients can also con-
tinue to have persistent or smoldering symptoms that affect their
quality of life. Elective sigmoid resection has shown to improve qual-
ity of life in patients with persistent or recurrent symptoms.11 13 The
DIRECT trial was a multicenter trial which randomized patients with
Disclosure: The authors reported no potential conflicts or funding.
*Corresponding author.
E-mail address: jason.hall@bmc.org (J.F. Hall).
uncomplicated diverticulitis to either conservative management or
elective laparoscopic surgical resection. Patients who were recruited
had persistent abdominal symptoms or 3 episodes within 2 years.
Although the trial was terminated prematurely due to difficulties in
recruitment, their preliminary results showed that the quality of life
at 6 months follow up was higher in those who received surgical
treatment. In addition, of those who underwent conservative man-
agement, 23% underwent elective resection due to ongoing symp-
toms. After repeated episodes of uncomplicated diverticulitis, effects
of continued medical management and quality of life should be con-
sidered including missed work, need for hospitalization, etc.
The updated 2020 ASCRS Practice Guidelines advise surgeons to
individualize the decision to operate after an episode of acute uncom-
plicated diverticulitis.
Emergency surgery
Although a majority of hospitalized patients with diverticulitis
respond to non-operative treatment, up to 20% have failure of treat-
ment and may require emergent operative management.9,14 The
need for emergency surgery depends on the patient’s clinical picture.
Patients with multi-quadrant peritonitis, systemic inflammatory
response due to purulent, or feculent peritonitis are advised to
undergo emergent sigmoid colectomy. In those that undergo emer-
gency colectomy for diverticulitis, the 30 day mortality is 5.1- 7.6%.
Predictors of mortality include older age greater than 80 years,
poorer functional class, dyspnea, ascites, recent radiotherapy, cortico-
steroid use, ASA class 4 or 5, creatinine >1.2, and albumin <2.5.15
This study found that those with 7 of these predictors had a 75% mor-
tality rate. In highly selected patients, non-operative treatment can
be attempted in the acute setting. These include patients with

https://doi.org/10.1016/j.scrs.2020.100799
1043-1489/© 2020 Published by Elsevier Inc.
2 N.E. Kim, J.F. Hall / Seminars in Colon and Rectal Surgery 32 (2021) 100799
pneumoperitoneum but without diffuse peritonitis, successfully
avoiding surgery as an emergent procedure.16
It is important to note that the rate of emergency surgery from
non-elective admissions has shown a downward trend from 20 to
10% although the rate of elective colectomy for diverticulitis has
increased.17
Complicated diverticulitis
Complicated diverticulitis is defined as diverticulitis associated
with abscess, fistula, obstruction, bleeding or perforation. There are
clearer indications for surgery in a subset of patients who have com-
plaints of fistula, obstruction, or recurrent diverticular bleeding. Fis-
tulas can present with a range of symptoms, including pneumaturia
and fecaluria in those with colo-vesicular fistulas and vaginal air or
stool per vagina in those with colo-vaginal fistulas. Obstructions
present most commonly with abdominal distension, nausea or vom-
iting. Both of these categories of patients should generally undergo
elective or semi-elective resection of their diverticular disease.18
Complicated diverticulitis with abscess can be managed in a num-
ber of different ways including operatively, nonoperatively, with
antibiotics, or percutaneous drainage. The recurrence rate after com-
plicated diverticulitis ranges from 25.5- 60.5%.19 22 After an episode
of complicated diverticulitis, patients are significantly more likely to
have recurrent diverticulitis.19 21,23 25 Meta-analysis shows that
there was a 28% recurrence rate in those initially presenting with a
diverticular abscess.26 A systematic review of patients undergoing
non-operative treatment for Hinchey class Ib and II showed a cumu-
lative failure rate (emergency surgery, readmission or mortality) of
20%.14 In another systematic review of non-operative management
for acute complicated diverticulitis, 60.9% of all recurrences were
found to be complicated recurrences.22
Patients presenting with a recurrence after a complicated divertic-
ulitis episode typically present with a more severe presentation. In a
retrospective review from a tertiary hospital, 45.6% of patients who
had recurrent diverticulitis after initial non-operative management
of a complicated diverticulitis presented with a worse Hinchey class.
26% of these required an urgent operation, compared to 11.9% who
required an urgent operation on initial presentation.20 The presence
of an abscess of at least 5 cm has been associated with need for sur-
gery on follow up.19
In patients with significant comorbidities, non-operative manage-
ment can be considered over interval elective surgery.27 Those who
have higher risk abscess, with size >5 cm, pelvic abscess or requiring
percutaneous drainage can be considered for interval surgery.28
Laparoscopic lavage
There have been several randomized trials evaluating laparo-
scopic peritoneal lavage as an alternative to resection in select
patients with perforated diverticulitis. The procedure is performed
by first inspecting the peritoneal cavity with a laparoscope. Any
adhesions should not be disrupted, and the pouch of Douglas should
be accessed and thoroughly washed. The peritoneal cavity is then
thoroughly irrigated with warm saline until return of clear fluid.
The Laparoscopic Peritoneal Lavage of Resection for Generalized
Peritonitis for Perforated Diverticulitis (LADIES) trial had three sepa-
rate arms investigating the approach to acute diverticulitis, compar-
ing laparoscopic lavage, sigmoidectomy with end-colostomy
(Hartmann’s procedure) and sigmoidectomy plus primary anastomo-
sis(29). The trial enrolled patients with purulent perforated diverticu-
litis and excluded those with fecal peritonitis. The primary endopoint
was major morbiditiy and mortality. An interim analysis showed
increased rates of serious short term adverse events such as death,
surgical reintervention, dehiscence, abscess requiring drainage, myo-
cardial infarction, renal failure and respiratory insufficiency in the
group undergoing laparoscopic lavage compared to sigmoidectomy
(39% vs 19%, p-value= 0.04).29 Due to these preliminary results of
increased events in those enrolled in the lavage group, the trial was
terminated early. The study concluded that the high morbidity and
mortality in the lavage group could in part be due to the failure to
identify Hinchey III from Hinchey IV perforated diverticulitis and
underlying colorectal cancer. Based on the results of this study, lapa-
roscopic lavage could be considered in carefully selected patients by
identifying those that would be at higher risk for complications after
undergoing laparoscopic lavage.
The Diverticulitis laparoscopic lavage versus resection (DILALA)
trial included patients who were found to have Hinchey grade III on
diagnostic laparoscopy and were randomized intraoperatively to
either laparoscopic lavage versus open Hartmann procedure. Those
randomized to laparoscopic lavage had shorter time in the recovery
unit, shorter hospital stay (median 6 vs 9 days, p value <0.05) but a
longer time with abdominal drainage (median 3 vs 2 days, p-value
<0.05). There was no statistically significant difference with mortal-
ity and reoperation and complications.30 The authors concluded that
laparoscopic lavage was feasible and safe to perform based on short
term outcomes.
Another randomized control trial (SCANDIV) trial assigned
patients to undergo laparoscopic lavage or colon resection. Patients
with imaging showing free air and findings of perforated diverticuli-
tis were included. The primary outcome of severe complications at
90 days after surgery was defined by Clavien-Dindo greater than IIIa.
There was no statistically significant difference in the rate of severe
complications and mortality between the laparoscopic lavage group
and resection group. Patients who underwent a laparoscopic lavage
more likely to require a secondary surgical procedure because of
complications.31 This study concluded laparoscopic lavage led to
worse secondary outcomes and could not support the procedure as a
treatment of perforated diverticulitis.
National guidelines from the ASCRS guidelines recommend against
performing laparoscopic lavage in patients with feculent peritonitis. In
patients presenting with purulent peritonitis, colectomy is recom-
mended over laparoscopic lavage as there is a higher rate of re-inter-
vention.32 SAGES published recommendations based on a conference
where members voted on consensus statements. The recommendation
was to consider laparoscopic lavage in select Hinchey III patients and
monitor for complications.33 Similarly ESCP guidelines were published
based on expert consensus. The recommendation for patients with
fecal peritonitis was resection, not laparoscopic lavage. For select
patients with Hinchey III, laparoscopic lavage is feasible.34 Currently
there is a lack of a standardized selection criteria for those who may
benefit from laparoscopic lavage and avoid resection.
Approach to surgery
Surgical planning
Initial management and diagnosis of acute diverticulitis involves
assessing the location and extent of the disease. Computed tomogra-
phy (CT) has been shown to be the most appropriate diagnostic
method of choice.35 The use of CT imaging allows for assessing the
severity of disease and extent of the diseased bowel to guide surgical
management. In cases where CT is either not feasible or not available,
such as contrast allergy or pregnancy, other modalities may be used.
These include the ultrasound or MRI as an alternative means of diag-
nosis. Ultrasound has been found to have a sensitivity of 84 85% and
a specificity of 80 93% on systematic review36 Recent literature has
also shown similar sensitivity and specificity compared to CT espe-
cially in cases of uncomplicated diverticulitis and has been suggested
as an initial diagnostic tool prior to CT.37 Ultrasound can diagnose
and assess acute diverticulitis by detecting the following findings:
segmental colonic wall thickening of greater than 5 mm, inflamed
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diverticulum and pericolic tissue changes.37 MRI can also be used in
cases where a CT is contraindicated due to radiation, and when a
complicated diverticulitis is suspected and US may not be sufficient.
Surgical principles
Main surgical principles of resection in acute diverticulitis include
resection of all abnormal tissue and an anastomosis of healthy large
bowel to normal rectum. Dissection starts medial to lateral by creat-
ing a plane below the inferior mesenteric artery (IMA). Occasionally,
a medial to lateral approach is not possible and therefore a lateral to
medial approach can be taken. The left ureter and gonadal vein are
identified and kept out of harm’s way. The IMA is then divided, and
the sigmoid colon mobilized to the level of the splenic flexure. Mobi-
lization of the splenic flexure may need to be mobilized in order to
perform a tension-free anastomosis. Diverticulosis may be present in
the proximal aspect of the bowel and this is not an indication for
resection. However, it is important to not incorporate diverticula
directly into the anastomosis, as it may cause an anastomotic leak.
The distal extent should be healthy normal rectum as an anastomosis
to distal sigmoid has been found to confer a higher risk of recurrent
diverticulitis.38
After resection, the decision to create an anastomosis should be
dependent on several factors. The options include a primary colorec-
tal anastomosis (PA) with or without a diverting colostomy or ileos-
tomy, or an end-colostomy with a Hartmann’s procedure (HP). HP
was considered the standard procedure historically, however an
increasing number of studies show improved morbidity and mortal-
ity with resection and PA. A systematic review analyzing observa-
tional studies showed a lower mortality rate in those undergoing
PA.39 A randomized control trial comparing HP vs PA showed that
there was a comparable complication rate but a significantly reduced
rate of serious complications, operating time and hospital costs in
those with PA.40 There was no difference in mortality. The DIVERTI
trial was a multicenter randomized controlled trial also comparing
PA to HP.41 There was no significant difference in overall mortality
rate but there was a higher rate of stoma reversal in the PA arm. The
LADIES trial compared sigmoidectomy with PA with or without
defunctioning ileostomy to HP.41 The results showed again no signifi-
cant differences in short term morbidity and mortality after the index
procedure but there was a higher 12-month stoma free survival in
those undergoing PA.42
In an analysis of patients undergoing emergent operation for
acute diverticulitis, PA with a diverting loop ileostomy was found to
be as safe, with no difference in post-operative morbidity or mortal-
ity.21 In select patients, PA with a stoma can be a surgical option.43
Overall, the recurrence rate after surgery is estimated at 5% in 5 years
post-operatively.38
Operative approach
Laparoscopic operations for acute diverticulitis in the elective set-
ting have been associated with lower morbidity, mortality and
shorter hospital length of stay.44 47 Even in patients with compli-
cated diverticular disease with fistula, laparoscopic colectomy has
been found to have comparable complication rates compared to open
sigmoidectomy.48
Laparoscopic surgery can have significant rates of conversion
rates, ranging from 5.2 to 26%.28,49 Robotic surgery may have techni-
cal advantages over laparoscopic approach that includes better dex-
terity, superior visual field and better ergonomics. Robotic surgery in
diverticular disease has shown to have fewer complications and
shorter length of stay compared to laparoscopic surgery.50 In addi-
tion, there is a lower risk of conversion with robotic surgery, although
there is an increase in hospital cost.51,52 Other studies have found
there is a shorter duration of ileus post-operatively.50,53
3
Conclusion
Acute diverticulitis is a prevalent disorder associated with mor-
bidity and mortality. More than 50% of patients 60 years and older
have diverticulosis and of these 5% will develop acute diverticulitis.54
Management depends on the severity and complications associated
with the disease on initial presentation. Acute uncomplicated diver-
ticulitis has a recurrence rate of 15 26% and increases with every
subsequent recurrence. However, complicated recurrence and emer-
gency surgery associated with that recurrence is rare. Surgical man-
agement for acute uncomplicated diverticulitis should be managed
according to individual factors. Acute complicated diverticulitis with
an abscess should be considered for interval elective surgery. In those
with fistula, obstruction or bleeding should also be considered for
elective or semi-elective surgery. Surgery for acute diverticulitis
should attempt to resect all diseased portions of the colon and create
a primary anastomosis where possible, with or without a diverting
ostomy. Laparoscopic and robotic approaches have been shown to
have equivalent outcomes, with benefits of shorter lengths of stay
and post-operative ileus.
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