Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis
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SIRC INVITED REVIEW
Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis Augusto Lauro1 · Eleonora Pozzi1 · Samuele Vaccari2 · Maurizio Cervellera1 · Valeria Tonini1 Accepted: 15 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective. Keywords Complicated diverticulitis · Percutaneous drainage · Laparoscopic lavage · Emergency surgery · Elective surgery Abbreviations 5-ASA 5-Aminosalicylic acid AD Acute diverticulitis CRP C reactive protein CT Computed tomography DD Diverticular disease HP Hartmann’s procedure IBS Inflammatory bowel disease LL Laparoscopic lavage NSAIDs Non-steroidal anti-inflammatory drugs PCD Percutaneous drainage RCTs Randomized control trials SUDD Symptomatic uncomplicated diverticular disease WSES World Society of Emergency Surgery
* Samuele Vaccari [email protected] 1
Emergency Surgery Department, St. Orsola University Hospital, Bologna, Italy
Department of Surgical Sciences, Umberto I University Hospital - La Sapienza, Rome, Italy
2
Introduction Definition Colonic diverticulitis is a common disease in Western countries, with increasing incidence worldwide due to lifestyle and dietary changes. Diverticula originate from herniation of the mucosa and submucosa through the muscle layer where vasa recta penetrate in the colonic wall. In Western industrialized countries, diverticulosis more frequently occurs in the left colon, especially the sigmoid, whereas in Asian populations diverticula primarily involve the right colon [1, 2]. Despite its increasing incidence at younger ages, diverticulosis remains more common in elderly patients; its prevalence increases with age, in particular in patients older than 70 years [1].
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