Surgery for Diverticulitis in the 21st Century a Systematic Review

This systematic review sought to review primary data since 2000 guiding decision making, technical consideration, and surgical outcomes of sigmoid diverticulitis. Authors searched the National Guideline Clearinghouse, PubMed, and Cochrane databases for primary literature pertaining to diagnosis and management of acute, recurrent, and chronic diverticulitis. After excluding case series with < 30 patients and studies with data accrued exclusively before 2000, because of significant differences in management before that time, the review was left with 68 studies that were almost exclusively observational. Urgent surgery for acute diverticulitis is indicated in patients with sepsis and diffuse peritonitis, or failure to improve despite medical management with or without percutaneous drainage. The review quotes two single-institution studies that suggest a potential role for medical management of patients with complicated acute diverticulitis (presence of 1 or more: extraluminal air, fluid, or abscess) in absence of sepsis. The studies report of these patients, 18% to 27% received percutaneous drainage and 7% to 12% required surgery. Evidence suggests if abscess is present, there is a 3 times higher recurrence rate (41%) if not treated with surgery and > 50% need for eventual surgery. However, other papers show a similar recurrence and complication rate in diverticulitis complicated by abscess treated with percutaneous drainage. Despite a potential decrease in recurrence and complication after treated with percutaneous drainage of abscess, it is still typically encouraged for all complicated diverticulitis to undergo delayed elective resection because of reported increase in late complications. Complicated recurrence after recovery from an uncomplicated episode is < 5%. Age of onset younger than 50 years old and two or more episodes do not increase risk of complications. Recurrence rates range from 10% to 35% after uncomplicated diverticulitis, and it is generally not recommended to have an elective resection irrespective of the number of uncomplicated episodes. Elective resection should be considered on an individual approach, taking into account severity of prior episodes, patient specific risk factors for disease and surgery (specifically immunosuppression, collagen vascular disease, glucocorticoid use and malnutrition), ongoing symptoms, patient preferences, and chronic symptoms may persist after resection in 5% to 22% of patients. Although controversial, many authors recommend that after initial episode of diverticulitis, endoscopic or fluoroscopic evaluation should be obtained to evaluate for neoplasm, Crohn’s disease, and ischemic colitis. The opposed parties argue that there is low yield for routine evaluation outside of standard colorectal cancer screening in the absence of other clinical indications.