Version May 2024
INTRODUCTION — Diverticular disease of the colon is an important cause of hospital admissions and a significant contributor to health care costs in industrialized nations [1,2]. In Western countries, the majority of patients present with sigmoid diverticulitis [3,4].
Most patients with acute sigmoid diverticulitis are treated medically; surgery is only indicated when diverticulitis is either not amenable or is refractory to medical therapy (algorithm 1) [5-8]. Approximately 15 percent of patients will require surgery for diverticular disease [7]. In the United States, diverticular disease is the leading indication for elective colon surgery [9]. For patients who require surgery for diverticulitis, the choice of techniques depends upon the patient's hemodynamic stability, extent of peritoneal contamination, and surgeon experience/preference [10].
Surgical treatment of acute colonic diverticulitis and its acute complications (perforation, abscess formation, or intractability) is described here. Diverticular fistulas, bleeding, and stricture/obstruction, which are typically subacute or chronic sequelae of diverticulitis, are discussed in other topics:
●(See "Diverticular fistulas".)
●(See "Colonic diverticular bleeding".)
●(See "Large bowel obstruction".)
The diagnosis and medical management of acute diverticulitis are discussed separately. (See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults" and "Acute colonic diverticulitis: Medical management".)
PERFORATION — While most patients with freely perforated diverticulitis require surgery, the choice of techniques largely depends upon the extent of peritoneal contamination as assessed by the Hinchey classification system [11]:
●Stage I – Pericolic or mesenteric abscess
●Stage II – Walled-off pelvic abscess
●Stage III – Generalized purulent peritonitis
●Stage IV – Generalized feculent peritonitis
In general, the majority of microperforations (not included in the Hinchey classification), Hinchey I perforations, and Hinchey II perforations can be managed nonoperatively, while most Hinchey III and IV perforations require surgical intervention.
Free (frank) perforation — Acute diverticulitis with free (frank) perforation (Hinchey III or IV) is a life-threatening condition that mandates emergency surgery [7,8,12-14]. The primary goal of surgery is to obtain source control by removing the perforated colonic segment; the secondary goal of surgery is to restore intestinal continuity [15-19], the feasibility of which is predicated upon a patient's hemodynamic stability and the degree of peritoneal contamination.
Unstable patients — For patients who are hemodynamically unstable due to perforated diverticulitis and who do not have the physiologic reserve to tolerate a colon resection and reconstruction, damage control surgery should be expedited to obtain source control of their sepsis, delaying less critical portions of the operation until after appropriate resuscitation [14,20,21]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)
While damage control surgery always consists of peritoneal lavage, temporary abdominal closure, and a second look, some surgeons also perform a limited colonic resection, then either leave the colon stapled off in situ or construct a colostomy (ie, Hartmann's procedure with temporary abdominal closure) [20]. In a study of 58 patients with perforated diverticulitis with generalized peritonitis, the use of damage control strategies resulted in a 9 percent mortality rate, while 44 of 53 surviving patients were stoma free [22].
Stable patients with feculent peritonitis — For stable patients with feculent peritonitis (ie, Hinchey IV diverticulitis), we suggest Hartmann's procedure [14]. Primary anastomosis is generally contraindicated because of the peritoneal contamination and inflammation.
Hartmann's procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, and then reversing the colostomy in the future (figure 1) [16]. Because creating a mucous fistula by bringing the distal end of the transected bowel through the abdominal wall is often not possible after resecting the entire sigmoid colon, many surgeons mark the rectal stump with a long nonabsorbable suture and tack it to the anterior abdominal wall or sacral promontory to help identify the rectal stump at the second-stage operation.
Subsequent closure of the colostomy is a technically difficult operation associated with high morbidity and mortality rates [23,24]. As a result, colostomy closure is only performed in approximately 50 to 60 percent of all patients after a Hartmann's procedure [25-27]. In the author's practice, patients with fecal contamination of the abdominal cavity at the index operation are usually reversed after approximately one year; those without fecal contamination can usually be reversed sooner in three to four months. Colostomy reversal should be approached cautiously for patients with obesity and a short rectal remnant because the operation is technically difficult and the functional outcomes (eg, bowel control) are typically poor.
Stable patients with purulent peritonitis — For stable patients with purulent peritonitis (ie, Hinchey III diverticulitis), Hartmann's procedure is also the most commonly performed procedure [28]. However, the surgeon may choose to restore bowel continuity with or without fecal diversion based on patient and intraoperative factors as well as their own experience [10].
Primary anastomosis with proximal diversion — Some European authors have advocated primary anastomosis with proximal diversion (PAPD) (figure 2) in select patients with Hinchey III perforated diverticulitis [14]. Limited data suggest that it may have similar mortality, lower morbidity, and lower stoma rate at 12 months compared with Hartmann's procedure.
●In a randomized trial of 62 patients with left-sided colonic perforation due to Hinchey III or IV diverticulitis, patients treated with a primary anastomosis with diverting ileostomy, compared with patients treated with a Hartmann's procedure, had similar mortality (9 versus 13 percent) and morbidity rates (75 versus 67 percent) after the first operation [29]. However, a greater percentage of patients treated with a primary anastomosis with diverting ileostomy underwent stoma reversal (90 versus 57 percent), and reversal of the diverting ileostomy in those patients required less operative time (73 versus 183 minutes) and a shorter length of hospital stay (six versus nine days) and resulted in fewer serious complications (0 versus 20 percent) compared with colostomy reversal in patients treated with a Hartmann's procedure.
●In another French trial (DIVERTI), 102 patients with Hinchey III or IV perforated diverticulitis were randomly assigned to primary anastomosis or Hartmann's procedure [30]. At 18 months, the mortality and morbidity rates were similar between the two groups, but patients who underwent primary anastomosis were much less likely to still have a stoma (4 versus 35 percent). Two-thirds of patients underwent primary anastomosis with a protective stoma and one-third without it. That decision was not randomized but made by surgeons intraoperatively. Although the morbidity rate was lower without a protective stoma, this result was likely biased, as all but one patient without a stoma had Hinchey III disease.
●A third multinational trial comparing primary anastomosis (without diversion) with Hartmann's procedure in patients with Hinchey III or IV perforated diverticulitis failed to reach any conclusion after closing prematurely due to poor accrual [31].
A 2018 systematic review and meta-analysis of randomized trials (including the three above) found that primary resection and anastomosis had similar major complication and mortality rates compared with Hartmann's procedure. However, patients were more likely to be stoma free (relative risk [RR] 1.4, 95% CI 1.18-1.67) and to avoid major complications related to the stoma reversal procedure (RR 0.26, 95% CI 0.07-0.89) after primary resection and anastomosis than after Hartmann's procedure [32]. A 2019 systematic review and meta-analysis of 22 observational studies and the three trials reached a similar conclusion that both procedures were acceptable [33].
The two procedures have been compared in several large administrative database studies as well.
●In an analysis of over 130,000 patients undergoing either primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis (not stratified by Hinchey classification, but about 90 percent underwent surgery for perforation), the mortality (2.9 versus 7.6 percent) and morbidity rates (49 versus 55 percent) were comparable [34]. Although patients who underwent Hartmann's procedure were generally sicker (eg, more likely to be in septic shock [11 versus 5 percent]), primary anastomosis with diverting loop ileostomy was not associated with increased mortality or morbidity when compared with Hartmann's procedure in multivariate analysis. The majority of patients underwent Hartmann's procedure, and only 7.6 percent underwent primary anastomosis with diverting ileostomy.
●An administrative database study of over 10,000 patients undergoing urgent or emergency colon surgery for diverticulitis found that both postoperative mortality (15 versus 7.4 percent) and morbidity rates (58.2 versus 39.5 percent) were significantly higher when noncolorectal surgeons performed primary anastomosis with proximal diversion compared with Hartmann's procedure, while the postoperative mortality (3.7 versus 5.3 percent) and morbidity rates (48.2 versus 43.4 percent) were comparable between the two procedures when performed by colorectal surgeons [35,36].
●In a third study of 34,126 patients who required nonelective diversion for acute diverticulitis in a United States nationwide cohort, 95 percent underwent Hartmann's procedure; 5 percent underwent primary anastomosis with proximal diversion [37]. By inverse probability treatment weight analysis, the odds of mortality, complications, and nonhome discharge were similar for proximal diversion compared with Hartmann's procedure. Proximal diversion was associated with a higher rate of readmission within 90 days (22 versus 14 percent) but a greater chance of ostomy reversal than Hartmann's procedure (hazard ratio 1.46, 95% CI 1.08-1.99).
Rarely performed procedures — Drainage procedures are rarely performed because they do not definitively address the underlying diverticular disease, and some studies suggest poorer outcomes in patients undergoing lavage. However, they may be useful in treating septic patients who are too ill to tolerate a resectional procedure.
Laparoscopic lavage — In the 1990s, laparoscopic lavage and drainage were introduced to avoid laparotomy and fecal diversion in patients with complicated diverticulitis [38-41]. Compared with other surgical options, laparoscopic lavage has been shown to decrease stoma rate within 90 days (RR 0.18; 95% CI 0.12-0.27); however, it does not decrease one-year mortality rate and actually increases short-term morbidity rate due to higher complication and reintervention rates [14,42]. Therefore, laparoscopic lavage should only be performed in selected patients with Hinchey III (purulent) perforated diverticulitis and by experienced surgeons, after they are counseled regarding the higher complication and reintervention rates. Hinchey IV (feculent) perforated diverticulitis should be treated with Hartmann's procedure, while Hinchey I or II (abscess) diverticulitis is likely to respond to nonoperative management. (See 'Localized perforation (ie, abscesses)' below.)
Although earlier retrospective studies found a low mortality rate of 2 percent and avoidance of a permanent stoma in the majority of patients who underwent laparoscopic lavage [43], subsequent randomized trials performed against resectional procedures in the 2000s reported conflicting results:
●In the SCANDIV trial, 199 patients suspected of having perforated diverticulitis based upon detection of free air by abdominal computed tomography (CT) scan were randomly assigned to undergo emergency laparoscopic lavage or sigmoidectomy [44]. Compared with sigmoidectomy, laparoscopic lavage achieved similar mortality (13.9 versus 11.5 percent) and severe morbidity rates (30.7 versus 26 percent) at 90 days. However, patients who were treated with laparoscopic lavage were more likely to require reoperation (20.3 versus 5.7 percent) for complications such as secondary peritonitis (six versus zero patients) or missed sigmoid cancer (four versus zero patients). A follow-up study of trial participants found that, at five years, the rates of morbidity, mortality, and secondary procedures (including stoma reversal) were equal between the two groups, and there were no differences in quality-of-life measures [45]. There were more diverticulitis recurrences in the lavage group but higher stoma prevalence rates in the resection group.
●The LOLA trial, which included 90 patients with purulent perforated diverticulitis, showed that laparoscopic lavage produced a higher combined major morbidity and mortality rate within 30 days compared with sigmoidectomy (39 versus 19 percent) [46]. At 12 months, the rates were comparable between the two groups (65 percent for lavage versus 63 percent for sigmoidectomy).
●The DILALA trial randomly assigned 83 patients to laparoscopic lavage or Hartmann's procedure after a laparoscopic diagnosis of purulent perforated diverticulitis [47,48]. The mortality rates were similar at both 90 days (8 versus 11 percent) and one year (14 versus 15 percent); the major morbidity rates were similar at 30 (13 versus 18 percent) and 90 days (21 versus 25 percent). The reoperation rates were similar at 30 days (13 versus 17 percent). At one year, however, fewer patients required reoperation after laparoscopic lavage (28 versus 63 percent). In addition, laparoscopic lavage resulted in shorter operative time (1 versus 2.5 hours) and hospital stay (6 versus 9 days for index admission; 8 versus 14 days at one year). At two years, still fewer patients required one or more reoperations after laparoscopic lavage than after Hartmann's procedure (42 versus 68 percent), while the mortality rate (14 versus 18 percent) and total days of hospital stay (18 versus 24) were statistically similar between the two groups [49].
Although laparoscopic lavage has the purported advantages of reduced morbidity and mortality, a systematic review and meta-analysis of randomized trials (including the three above) found that major complications were more frequent after laparoscopic lavage than sigmoidectomy, whereas postoperative mortality rates (RR 1.03; CI 0.45-2.34) were not different between the two procedures [32,42]. Weighing the lower stoma rate against the higher risks of complication and reoperation, we do not recommend routine laparoscopic lavage for Hinchey III or IV perforated diverticulitis. Hartmann's procedure remains our standard treatment for Hinchey III or IV perforated diverticulitis.
Laparoscopic lavage was originally intended for purulent (Hinchey III) but not feculent (Hinchey IV) perforated diverticulitis. But in common practice, it is often difficult to exclude fecal peritonitis and/or sigmoid carcinoma during the preoperative evaluation. If a surgeon chooses to perform laparoscopic lavage, they must exclude fecal perforation (Hinchey IV) or a visualized perforation by diagnostic laparoscopy and either colon cancer or ongoing colonic air leak (from perforation) by intraoperative sigmoidoscopy.
Patients who undergo laparoscopic lavage should be advised that a reoperation (usually Hartmann's procedure) may be necessary if laparoscopic lavage fails to control the sepsis or a sigmoid carcinoma is later found. In a multicenter, prospective, noncomparative study (the LLO study), 212 patients underwent laparoscopic lavage for laparoscopy-confirmed Hinchey III perforated diverticulitis [50]. The short- and long-term success rates of laparoscopic lavage in this cohort of patients were 74.5 percent (discharged without further surgery or readmission in 60 days) and 65.4 percent (no surgery for the initial admission or recurrence), respectively. Only one patient had a colon cancer, which required reoperation. Since one-quarter of patients will not have sepsis control with laparoscopic lavage alone, those who undergo laparoscopic lavage must be able to tolerate persistent or recurrent infection. Thus, frail, septic patients or those with major comorbidities are not good candidates for laparoscopic lavage [41]. A fit patient with previous acute diverticulitis and without severe sepsis may be a better candidate for the procedure [50].
In a British registry-based study of 499 propensity score-matched patients undergoing emergency surgery for Hinchey III perforated diverticulitis, laparoscopic lavage was associated with fewer overall complications within 90 days, as defined by the Comprehensive Complication Index (CCI) score, and shorter hospital stay at both index admission and in total within 90 days [51]. Patients who underwent laparoscopic lavage had more infectious complications and readmissions, whereas those who underwent resection suffered more cardiovascular and other complications.
Three-stage procedure — A legacy procedure for colonic perforation includes three stages: the first stage of draining but not resecting the diseased segment and construction of a proximal diverting stoma, the second stage of resecting the diseased segment with a primary anastomosis under the protection of the proximal stoma, and the third stage of closing the proximal stoma. Until the 1980s, the three-stage procedure was felt to be the safest approach to perforated diverticulitis.
Since then, the three-stage procedure has been largely replaced by other procedures (eg, the Hartmann's procedure) with lower postoperative mortality rates (26 versus 7 percent) [52,53]. In contemporary practice, the three-stage procedure is only performed when inflammation precludes safe pelvic dissection of the colon from critical sidewall structures (eg, iliac vessels and ureters) or when the patient is unstable. Drainage and fecal diversion in these situations can serve as a temporizing measure to allow treatment of infection and inflammation before further surgery or transfer to a more experienced center. (See "Large bowel obstruction", section on 'Diverticular disease'.)
Localized perforation (ie, abscesses) — Localized perforations present acutely as a mesocolic or pelvic abscess (Hinchey I or II). Hinchey I or II diverticulitis is characterized by one or more localized abscesses in the pericolonic, mesenteric, or pelvic locations. In contemporary practice, diverticular abscesses are typically treated with percutaneous image-guided drainage or with intravenous antibiotics if the abscess is too small (<4 cm) or inaccessible to percutaneous drainage. Surgery may be indicated for patients who deteriorate or fail to improve within two to three days of percutaneous intervention or antibiotic therapy as a persistent intra-abdominal abscess is unlikely to respond to further nonoperative management. (See "Acute colonic diverticulitis: Medical management", section on 'Abscess'.)
Patients with a localized perforation can usually tolerate a preoperative bowel preparation. Thus, if the phlegmon or abscess can be resected with the colonic segment, a primary anastomosis can be performed in these patients. (See 'Colon resection with primary anastomosis' below.)
If there are concerns about either contamination or inflammation involving the surrounding tissue (eg, with a large pelvic abscess) but the bowel is not edematous, a primary anastomosis with or without a protective ostomy, depending upon the condition of the local tissue, can be performed. This is preferred to a Hartmann's procedure as a protective stoma is easier to reverse than an end colostomy with a rectal stump [54,55]. (See 'Primary anastomosis with proximal diversion' above.)
Microperforation — Microperforation, usually indicated by one or a few extraluminal air bubbles on CT images, and phlegmon are not considered complicated diverticulitis and thus can be managed nonoperatively with intravenous antibiotics and bowel rest [10]. (See "Acute colonic diverticulitis: Medical management", section on 'Microperforation'.)
Those with extraluminal air bubbles only on initial CT may develop an abscess on subsequent studies. In one study, the rate was 19 percent [56]. Patients with microperforation and an associated abscess should be treated accordingly as having complicated disease. (See "Acute colonic diverticulitis: Medical management", section on 'Abscess'.)
PERSISTENT SYMPTOMS — Patients may require colon surgery for diverticulitis because of persistent or chronic symptoms that interfere with quality of life. There is high-quality evidence that elective resection may improve short-term functional outcomes and quality of life for those who remain symptomatic despite optimal medical therapy [57].
●Failure of medical treatment – Patients who deteriorate or fail to improve after three to five days of inpatient intravenous antibiotics may require surgery during the same hospitalization as further medical therapy is unlikely to resolve their diverticulitis. (See "Acute colonic diverticulitis: Medical management", section on 'Failure of inpatient medical treatment'.)
●Chronic smoldering diverticulitis – Patients with acute diverticulitis who initially respond to medical treatment but subsequently develop recurrent symptoms, such as left lower quadrant abdominal pain, alteration in bowel movements, and/or rectal bleeding, are described as having chronic smoldering diverticulitis. If the symptoms persist for longer than six weeks, patients should be referred for surgical evaluation. However, since patients with irritable bowel syndrome or other functional gastrointestinal disorders may present similarly, patients with chronic symptoms after an acute diverticulitis attack must be evaluated carefully before being offered surgery. (See "Acute colonic diverticulitis: Medical management", section on 'Symptomatic patients after initial attack'.)
Colon resection with primary anastomosis — A one-stage procedure (ie, colon resection with primary anastomosis) is typically performed for patients with persistent or chronic symptoms from diverticulitis, as long as they can tolerate a bowel preparation preoperatively. (See 'Bowel preparation' below.)
To qualify for a one-stage resection, the bowel must be well vascularized and nonedematous and the anastomosis should be tension free and well prepared. The distal resection margin is typically placed in the upper third of the rectum, where the teniae coli converge. The proximal margin is placed where the colon becomes soft and nonedematous. It is not necessary to resect all diverticula-bearing colon proximal to the intended anastomosis to prevent recurrence, since diverticula in the transverse or descending colon rarely cause further symptoms [58]. (See 'Operative considerations' below.)
For patients with persistent or chronic symptoms of diverticulitis, intraoperative findings of free perforation may alter the operative plan to either a Hartmann's procedure (for Hinchey III or IV diverticulitis) or addition of a protective ostomy (for Hinchey I or II diverticulitis with surrounding inflammation or infection). In addition, as an unprotected primary anastomosis is also relatively contraindicated for patients with significant medical comorbidities, poor nutritional status, immunosuppression, or other factors that could lead to anastomotic complications [59], surgeons may also choose to protect the anastomosis in patients with one or more of the risk factors.
Open versus minimally invasive approach — A one-stage colon resection for diverticulitis can be performed open or minimally invasively (laparoscopic or robotic). The minimally invasive approach is preferred when feasible. Evidence suggests that laparoscopic surgery in this setting can be performed safely with superior short-term outcomes and comparable long-term outcomes [14,60-70].
At least three randomized trials have also been performed:
●In the Sigma trial (2009; 104 patients), laparoscopic surgery performed for Hinchey I and II diverticulitis was associated with a 15 percent reduction in major complication rates, less pain, improved quality of life, and shorter hospitalization, but a longer operating time compared with open surgery [71]. At six months, the advantage of laparoscopic surgery in major complication rate had increased to 27 percent [72]. A separate economic analysis showed that the total health care costs of laparoscopic and open surgery were similar [73].
●A second randomized trial (2010; 113 patients) found that, compared with open surgery, laparoscopic surgery resulted in a significantly shorter duration of postoperative ileus (76 versus 106 hours) and length of hospital stay (five versus seven days). However, the reduction in postoperative pain was less impressive (4 versus 5 on a visual analog pain scale), perhaps because patients were blinded to the surgical approach [74]. At 30 months, the only remaining benefit of the laparoscopic approach was slightly improved cosmetic outcomes (9 versus 8 on a 10 point scale) [75]. The median hospital cost was not different.
●A third randomized trial (2011; 143 patients) found that patients who underwent laparoscopic versus open surgery had similar complication rates and reported similar quality of life during the early postoperative period and at 12 months [76].
A 2017 Cochrane review of the above three randomized trials found insufficient evidence to either support or refute the superiority of laparoscopic surgery over open surgery for diverticular disease [77]. Additionally, in a meta-analysis of 19 nonrandomized studies comparing 1014 patients undergoing elective laparoscopic surgery with 1369 patients undergoing open surgery, open surgery was associated with significantly higher rates of wound infection (relative risk [RR] 1.85, 95% CI 1.25-2.78), blood transfusion (RR 4.0, 95% CI 1.67-10.0), postoperative ileus (RR 2.70, 95% CI 1.52-5.0), and incisional hernia (RR 3.70, 95% CI 1.56-8.33) [78]. The rates of serious complications (eg, anastomotic leak or stricture, inadvertent enterotomy, small bowel obstruction, intra-abdominal bleeding, or abscess formation) were comparable between the groups.
Data suggest that laparoscopic surgery for sigmoid diverticulitis can be safely performed in patients with obesity [79] and older adult patients [80].
Laparoscopic surgery for diverticular disease can be performed with the standard multiport technique or with a technique called single-incision laparoscopic colectomy (SILC). Studies showed that SILC is feasible and safe when performed by experienced surgeons [81,82]. In a prospective study of 330 patients with diverticular disease, patients who underwent SILC had lower peak pain scores compared with patients who underwent a standard laparoscopic procedure (4.9 versus 5.6) [81]. The techniques of single-incision laparoscopic surgery are discussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'.)
OBSTRUCTION — Patients who present with colonic obstruction attributable to acute diverticulitis should undergo surgical resection of the involved colonic segment or proximal fecal diversion if a resection cannot be performed safely. Because acute diverticulitis and colon cancer can both cause colonic obstruction and are difficult to distinguish by abdominopelvic CT (image 1), surgery in this setting is required to rule out cancer and also to relieve symptoms of obstruction.
Colonic obstruction due to diverticular disease is rarely complete, which allows bowel preparation to be attempted. Alternatively, on-table lavage can be used to clean out the fecal load, which may also permit a primary anastomosis.
Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis. In a systematic review, treating benign colorectal obstructions (most due to diverticulitis) with self-expanding stents resulted in more cases of perforation (12 versus 4 percent), stent migration (20 versus 10 percent), and recurrent obstruction (14 versus 7 percent) than stenting malignant colorectal obstructions [83]. When stenting was used as a bridging therapy to surgery, only 43 percent of patients with diverticulitis successfully avoided a stoma. (See "Enteral stents for the management of malignant colorectal obstruction".)
FISTULA — As a result of diverticulitis, a fistula can develop between the colon and another pelvic organ, such as the bladder (65 percent), vagina (25 percent), small bowel (7 percent), uterus (3 percent), or other sites. Diverticular fistulas rarely close spontaneously and therefore require surgical correction. The management of diverticular fistulas is discussed separately. (See "Diverticular fistulas".)
BLEEDING — Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding in adults. In most cases, the bleeding will stop spontaneously. However, if the bleeding persists, endoscopic, radiologic, or surgical intervention may be required. Segmental colectomy is performed when the source of bleeding can be localized with colonoscopy or angiography; subtotal colectomy is reserved for patients who continue to bleed without a documented site of bleeding; blind segmental resection should not be performed, due to a high rebleeding rate (approximately 40 percent). (See "Colonic diverticular bleeding".)
RISK REDUCTION (ELECTIVE SURGERY) — The 2020 American Society of Colorectal Surgeons (ASCRS) guidelines recommend elective surgery to patients who had a prior episode of complicated diverticulitis and those who are immunosuppressed regardless of symptoms because such patients could develop serious complications or die from recurrent attacks of diverticulitis [10].
Elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis when all infection and inflammation have resolved; earlier surgery has been associated with a higher conversion rate and a longer hospital stay [84]. In a retrospective study of 332 patients, those who underwent laparoscopic surgery prior to three months after the last acute episode were more likely to have residual inflammation (31 versus 11 percent), abdominal morbidities (21 versus 5 percent), and longer hospital stay (7.7 versus 5 days) compared with those who underwent surgery after three months [85]. A primary anastomosis without protective ostomy (ie, a one-stage procedure) is the standard procedure for diverticulitis. (See 'Colon resection with primary anastomosis' above.)
Patients with prior complicated attack — The 2020 ASCRS guidelines [10] recommend elective surgery for patients with one prior episode of complicated diverticulitis because some studies show that such patients are at a greater risk of developing complications or dying from a recurrent attack and therefore would benefit from early elective surgery [86,87].
As an example, in a retrospective study of over 200,000 patients admitted for diverticulitis, 85 percent were managed medically, of whom 16 percent suffered a recurrent attack [86]. The following complications of the initial episode of diverticulitis were independent predictors of mortality during the recurrent episode: bowel obstruction (hazard ratio [HR] 1.33, 95% CI 1.06-1.65), abscess (HR 2.18, 95% CI 1.60-2.97), peritonitis (HR 3.14, 95% CI 1.99-4.97), sepsis (HR 1.88, 95% CI 1.29-2.73), and fistula (HR 3.50, 95% CI 2.17-5.66). The mortality rate with elective surgery after the initial episode was substantially lower than the mortality rate with emergency surgery during the recurrent episode (0.3 versus 4.6 percent).
Healed diverticular abscess — Whereas surgery is almost always indicated for complications such as fistula, obstruction, stricture, and free perforation, the optimal management of a healed diverticular abscess is less certain [88], as some evidence suggests that it is not as significant a risk factor for future complicated recurrence. Thus, for patients with a healed diverticular abscess, we suggest basing the decision to operate on the persistence of symptoms and effect on quality of life, rather than mandating surgery solely to avoid recurrent attacks. This is especially true if the patient is medically complicated. The 2018 European Association of Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) consensus guidelines also suggested against routine surgery solely to prevent future attacks following a single episode of Hinchey I/II acute diverticulitis successfully treated nonoperatively [14].
Some studies report that recurrence after nonoperative treatment of diverticular abscesses is common (up to 61 percent) [87,89] or that most such patients (65 percent) will require surgery eventually for one reason or another [90]. Other data suggest that recurrence is infrequent (25 percent) [91-93] and that most can be managed nonoperatively [56,94,95], with only about 12 percent requiring nonelective resection [91,96].
The discrepancy between studies may originate from an imprecise definition of true recurrence (as opposed to unresolved index episode) [97]. Hence, we suggest basing the decision to operate on a patient's persistent symptoms as we would do for all colonic diverticular diseases, rather than solely on a history of diverticular abscess if it has completely healed. (See 'Persistent symptoms' above.)
Patients who are immunocompromised — Most surgeons would offer elective surgery to immunocompromised patients after a single attack of diverticulitis because they often require emergency surgery due to an atypical and delayed presentation. Elective surgery is associated with lower morbidity and mortality rates compared with emergency surgery in these and other patients. (See "Acute colonic diverticulitis: Medical management", section on 'Immunosuppression'.)
PERIOPERATIVE CONSIDERATIONS
Antibiotics — Patients undergoing emergency or urgent surgery for acute diverticulitis should already be on antibiotics (table 1 and table 2 and table 3), the duration of which is discussed separately. (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'Duration of therapy' and "Acute colonic diverticulitis: Medical management", section on 'Intravenous antibiotics'.)
Patients undergoing elective surgery for diverticular disease should receive prophylactic antibiotics within one hour of skin incision. The choice of antibiotics is discussed elsewhere (table 4). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Bowel preparation — In general, we recommend mechanical bowel preparation and oral antibiotics before all resectional colorectal procedures when feasible. Preoperative bowel preparation is possible for all patients undergoing elective surgery and selected patients undergoing urgent surgery for Hinchey I or II diverticulitis. The indications for bowel preparation and the choice of agents are further discussed elsewhere. (See "Overview of colon resection", section on 'Bowel preparation'.)
Stoma marking — Before surgery, patients should be advised of the possibility of a stoma, and the potential stoma site should be marked by a stoma therapist when available.
Prophylactic ureteral stent placement — There is no evidence for or against prophylactic ureteral stent placement. Surgeons may use it selectively based on imaging and patient characteristics (eg, for complex, chronic, or fistulous diverticular disease where anatomic distortion by the diverticular phlegmon is expected) [14]. (See "Overview of colon resection", section on 'Prophylactic ureteral stenting'.)
Patient positioning — We prefer a modified lithotomy or a split leg position, which permits intraoperative proctoscopy and the use of a circular stapler in case an anastomosis is performed.
Enhanced recovery protocol — Fast-track recovery protocols have been shown to incrementally improve outcomes of gastrointestinal surgeries, including elective colon surgery for diverticular disease. As an example, a retrospective study showed that managing patients according to a fast-track recovery protocol shortened the time from surgery to first solid meal (2.3 versus 3.6 days), first bowel movement (2.6 versus 3.5 days), and hospital discharge (3 versus 5 days), compared with traditional postcolectomy care [98]. In addition, patients on a fast-track recovery protocol also suffered fewer complications (15 versus 26 percent). Fast-track protocols in colorectal surgery are discussed elsewhere. (See "Enhanced recovery after colorectal surgery".)
OPERATIVE CONSIDERATIONS
●We prefer anatomic resection of the sigmoid colon with ligation of the inferior mesenteric artery (IMA). An anatomic resection ensures proper mobilization of the colon, hence the formation of a tension-free anastomosis.
●The descending colon should be fully mobilized to provide sufficient colonic length to ensure a tension-free anastomosis. Although routine splenic flexure mobilization has not been shown to decrease either perioperative morbidities [99] or recurrences [100], it may be required to further increase colonic length in selected patients. In several studies, splenic flexure mobilization was performed in about half of the patients [99,100].
●The colon should be transected in an area proximal to the involved segment/phlegmon that is devoid of gross inflammation. It is not necessary to resect all diverticula.
●Distal transection should occur at or below the rectosigmoid junction where the teniae coli coalesce, at the level of the sacral promontory. A colorectal anastomosis has a four times lower risk of disease recurrence compared with a colosigmoid anastomosis [100].
●Either a hand-sewn or stapled anastomosis can be performed based on surgeon preference, as there is no difference in outcomes [100]. For stapled anastomoses, the stapler not reaching and effacing the staple line of the rectal stump is indicative of residual sigmoid colon. In this situation, the residual sigmoid colon should be resected to prevent recurrences, as opposed to advancing the stapler out the anterior wall of the rectum [14]. An intraoperative leak test should be performed to evaluate the integrity of the anastomosis.
●As there is no evidence to support routine peritoneal drainage [101], whether to leave such a drain is left to the surgeon's discretion.
OUTCOMES — There have been few studies directly comparing the medical and surgical treatment of diverticulitis. In a multicenter trial (DIRECT) of 109 patients who either had three or more prior episodes of diverticulitis in the past two years or had chronic smoldering symptoms after a single episode, elective laparoscopic colon surgery resulted in superior quality-of-life scores at six months and five years compared with conservative management despite inherent surgical complications (11 percent anastomotic leak; 15 percent reintervention) [57,102] and was found to be cost effective at five years [103]. About half of the patients managed conservatively ultimately required surgery due to severe ongoing complaints [102].
In the LASER trial, which included 85 patients with either ≥3 episodes of recurrent diverticulitis, complicated diverticulitis, or chronic pain after diverticulitis, the Gastrointestinal Quality of Life Index (GIQLI) score improved 11.8 points in patients randomized to sigmoid resection and 0.2 points in patients randomized to conservative treatment between baseline and six months. However, 10 percent of those who underwent resection suffered severe complications (abscesses and anastomotic leaks) [104].
The mortality rates after colon surgery for diverticular disease range from 1.3 to 5 percent depending upon the severity of illness and the presence of comorbidities [15,105]. Emergency surgery for acute perforated diverticulitis has been associated with a mortality rate of 15 to 25 percent and a morbidity rate of up to 50 percent [15-18,53,106]. Specific complications of colon surgery are discussed elsewhere. (See "Management of anastomotic complications of colorectal surgery" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)
The incidence of postoperative complications following elective surgery for diverticular disease varies widely from 5 to 38 percent [71]. Laparoscopic surgery conveys a lower risk of postoperative complications compared with open resection [78].
Patients are typically cured of their diverticular disease after surgery. However, 15 percent will develop new diverticula in the remaining colon, and 2 to 11 percent will require repeat surgery [58,107,108]. Recurrences are more likely if the distal resection margin is not extended on to the rectum.
After surgery, up to 27 percent of patients may complain of persistent abdominal pain in the same location as their prior diverticular disease. Such patients require further evaluation by gastroenterologists as these symptoms are more attributable to coexisting functional intestinal disorders (eg, irritable bowel syndrome) rather than recurrent diverticulitis. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
In a retrospective study of 17,368 patients from the National Surgical Quality Improvement Program data (2012 to 2018) who underwent colectomy for acute diverticulitis, cancer was found in 164 (0.94 percent) [109]. Eighty-four percent of patients had locally advanced tumors (T3-4), and 37 percent had positive lymph nodes. In multivariate analysis, cancer was associated with sepsis, weight loss, and low albumin.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colonic diverticular disease".)
SUMMARY AND RECOMMENDATIONS
●Prevalence – Although most patients with acute diverticulitis can be treated medically, approximately 15 percent will require surgery for various indications. (See 'Introduction' above.)
●Frank perforation – Most patients with frankly perforated diverticulitis require surgery, and the preferred procedure depends upon the degree of perforation, the patient's hemodynamic stability, the extent of peritoneal contamination, and surgeon experience/preference. (See 'Perforation' above.)
•For unstable patients with perforated diverticulitis, we suggest damage control surgery with a limited resection or drainage-only procedure, rather than a formal resection and anastomosis (Grade 2C). (See 'Unstable patients' above.)
•For stable patients with feculent peritonitis (Hinchey IV perforated diverticulitis), we suggest a Hartmann's procedure, rather than a procedure involving a primary anastomosis or a nonresectional drainage procedure (Grade 2C). (See 'Free (frank) perforation' above.)
•For stable patients with purulent peritonitis (Hinchey III perforated diverticulitis), Hartmann's procedure is most commonly performed, but it is reasonable to perform a primary anastomosis with or without a diverting ostomy based on patient and intraoperative factors and surgeon experience. (See 'Stable patients with purulent peritonitis' above.)
•For stable patients with a localized perforation (Hinchey I or II diverticulitis) not amenable to nonoperative therapy, we suggest a primary anastomosis with or without a protective ostomy, depending upon the condition of the local tissue, rather than a Hartmann's procedure (Grade 2C). (See 'Localized perforation (ie, abscesses)' above.)
•Microperforation and phlegmon are not considered complicated diverticulitis and should receive initial medical treatment; most can be managed nonoperatively. (See "Acute colonic diverticulitis: Medical management", section on 'Microperforation'.)
●Smoldering diverticulitis – Patients with persistent or chronic symptoms despite medical therapy require urgent or semielective surgery. Most can undergo colon resection with primary anastomosis. The approach (open versus minimally invasive) is typically determined by surgeon experience. We suggest minimally invasive surgery when the requisite expertise is available (Grade 2C). (See 'Persistent symptoms' above.)
●Elective surgery – For asymptomatic patients with a prior episode of complicated diverticulitis or those who are immunocompromised, we suggest elective surgery to avoid the risk of future recurrence (Grade 2C). An exception is asymptomatic patients with a healed diverticular abscess, who are at lower risk for developing another complicated attack. Elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis when all infection and inflammation have resolved, and a primary anastomosis without protective ostomy (ie, a one-stage procedure) is standard. (See 'Risk reduction (elective surgery)' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Tonia Young-Fadok, MD, who contributed to earlier versions of this topic review.
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