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Perforated Diverticulitis: When Is Interval Resection Really Indicated?

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Current Common Dilemmas in Colorectal Surgery

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Abstract

Debated for years, the indication of whether or not to perform interval colectomy after perforated diverticular disease is again on trial, essentially due to the increasing use of laparoscopy to treat perforated colonic diverticular disease.

Most of the traditional indications for elective interval colectomy (after one acute episode for patients under 50 years of age, after two or more episodes of uncomplicated bouts of diverticulitis, or patients with complicated diverticular disease (abscess, perforation, fistula), not treated by emergency colectomy) have been recently challenged and are no longer the standard of care. According to the most recent (2014) practice parameters, neither young age nor the number of attacks of uncomplicated diverticulitis is a factor in defining the need for surgery. Patients in the so-called immunocompromised patient group, including transplant patients, patients on chronic corticosteroid therapy, or patients with chronic renal failure or collagen-vascular disease, may be candidates for early interval colectomy, while elective colectomy in anticipation of transplant remains controversial.

Routine elective surgery after nonsurgical treatment of abscesses remains debatable. As recommended by several learned societies, mesocolic abscesses of ≥5 cm or pelvic abscesses might justify surgery but the level of evidence is not strong.

For perforated diverticular disease, two randomized controlled trials comparing one-stage to two-stage treatment (initial suturing, drainage, colostomy) via laparotomy for perforated diverticular disease have published conflicting results. Since the advent of laparoscopic surgery, more and more patients are treated with simple lavage and/or drainage alone. The original tenors of this strategy advocated interval laparoscopic colectomy. While there are no clear recommendations from learned societies, the three randomized trials comparing the two strategies do not provide any definite answer as to whether interval colectomy is necessary or not, except for patients with diverticular disease complicated by hollow organ fistula or stenosis.

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Abbreviations

ACPGBI:

Association of Coloproctology of Great Britain and Ireland

ASCRS:

American Society of Colon and Rectal Surgeons

ASN:

Association of Surgeons of the Netherlands

DSS:

Danish Surgical Society

EAES:

European Association for Endoscopic Surgery

WSES:

World Society for Emergency Surgery

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Author information

Authors and Affiliations

  1. Department of Surgery, University Hospital of Graz, Graz, Austria

    Abe Fingerhut & Selman Uranues

  2. Department of General and Emergency IRCCS-Ca’ Granda-Policlinico Hospital, University of Milan, Milan, Italy

    Luigi Boni

  3. Department of Surgery, Section for Surgical Research, Medical University of Graz, Graz, Austria

    Viktor Justin

Authors
  1. Abe Fingerhut
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  2. Luigi Boni
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  3. Viktor Justin
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  4. Selman Uranues
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Correspondence to Abe Fingerhut .

Editor information

Editors and Affiliations

  1. London Health Sciences Centre, University Hospital, London, Ontario, Canada

    Christopher M. Schlachta

  2. Mount Sinai School of Medicine, New York, New York, USA

    Patricia Sylla

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Fingerhut, A., Boni, L., Justin, V., Uranues, S. (2018). Perforated Diverticulitis: When Is Interval Resection Really Indicated?. In: Schlachta, C., Sylla, P. (eds) Current Common Dilemmas in Colorectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-70117-2_13

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  • DOI: https://doi.org/10.1007/978-3-319-70117-2_13

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