Systematic review

doi:10.1111/j.1463-1318.2011.02766.x

Current status of the treatment of acute colonic diverticulitis: a systematic review

S. Biondo, J. Lopez Borao, M. Millan, E. Kreisler and E. Jaurrieta
Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, IDIBELL (Bellvitge Biomedical Research Institute), Barcelona, Spain Received 3 March 2011; accepted 4 May 2011; Accepted Article online 16 August 2011.

Abstract
Aim This paper addresses the current status of the treatment of acute colonic diverticulitis by an evidencebased review. Method A systematic search in PUBMED, MEDLINE, EMBASE and Google scholar on colonic diverticulitis was performed. Diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic signicance were reviewed. Criteria for eligibility of the studies were diagnosis and classication, medical treatment, inpatients and outpatients, diverticulitis in young patients, immunosuppression, recurrence, elective resection, emergency surgery, and predictive factors. Results Some 92 publications were selected for comprehensive review. The review highlighted that computed tomography is the most effective test in the diagnosis and staging of acute diverticulitis; outpatient treatment can be performed for uncomplicated diverticulitis in patients without associated comorbidities; conservative treatment is aimed at those patients with uncomplicated acute diverticulitis; elective surgery must be done on an individual basis; laparoscopic approach for elective treatment of diverticulitis is appropriate but may be technically complex; in perforated diverticulitis, resection with primary anastomosis is a safe procedure that requires experience and should take into account strict exclusion criteria. Conclusion The heterogeneity of patients with colonic diverticular disease means that both elective and urgent treatment should be tailored on an individual basis. Keywords Colonic diverticulitis, young patients, recurrence, outpatients, elective resection, emergency surgery

Introduction
The prevalence of diverticular disease is estimated to range between 20% and 60% in the general population [1,2]. Its incidence increases with age [3,4], and it is considered a disease of developed countries, related to a low-bre diet [5,6]. It is uncommon in populations under 40 years of age; it affects 510% of the population in the fth decade of life, 30% at age 60, and over 60% of people over the age of 80, without sex differences [79]. The most frequent complication of diverticular disease is acute diverticulitis (AD).

Although 75% of patients with diverticulosis remain symptom-free during their lifetime, the prevalence of patients that require medical or surgical treatment has increased 16% in the last 20 years, consequently increasing morbidity [79]. This paper aims to address the current status of the treatment of acute colonic diverticulitis after an evidencebased review.

Method
A comprehensive literature search for studies on colonic diverticulitis was performed. First, a systematic search in PUBMED, MEDLINE, EMBASE and Google scholar for all kind of papers (all publications to March 2011) was carried out. All case report papers and all the studies that dealt with

Correspondence to: Dr Sebastiano Biondo, Department of General and Digestive Surgery, Bellvitge University Hospital, c Feixa Llarga s n, LHospitalet de Llobregat, 08907 Barcelona, Spain. E-mail: sebastianobiondo@yahoo.com

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complications of diverticular disease with the exception of diverticulitis such as stenosis, massive haemorrhage and diverticular colonic stula were excluded from the review. Abstracts were reviewed and relevant papers were identied. Ten aspects of the publications (diagnosis, classication, medical treatment, inpatients and outpatients, diverticulitis and young patients, immunosuppression, recurrence, elective resection, emergency surgery, predictive factors) were proposed as the framework for the treatment of colonic diverticulitis. In a second stage, these aspects were reviewed to further select specic papers for each individual feature of colonic diverticulitis. Studies on diagnostic tools, randomized controlled trials, non-randomized comparative studies, observational epidemiological studies, national and international guidelines, reviews of observational studies on elective and emergency surgical treatment of diverticulitis, and studies of prognostic signicance were reviewed. Level of evidence and grade recommendation were provided for several aspects. After identifying relevant titles, the studies were read and eligibility conrmed. In the following systematic review, we followed the steps proposed in previous studies to arrive at meaningful conclusions [10]. Because of the signicant lack of randomized clinical trials on the topic of diverticulitis, quality assessment of most of the included studies was based on the list of 12 items proposed by the methodological index for non-randomized studies (MINORS) [11]. This is a validated instrument designed to assess the methodological quality of nonrandomized, comparative and non-comparative, surgical studies. All randomized clinical trials were included. Other papers have been selected for their scientic historical impact on the topic of diverticular disease. Revisions and editorial papers have been included when published in high quality journals. Evidence-based criteria were applied using the proposal of the Centre for Evidence Based Medicine of Oxford (CEBM) which is periodically updated and available at http://www.cebm.net (Tables 1 and 2). The papers meeting the inclusion criteria were evaluated by two reviewers and the methodological quality of each paper was assessed. Discordance in study inclusion between the two reviewers was resolved by a third reviewer and discussion. When multiple studies describing the same topic on diverticulitis were identied, level of evidence was taken into account. In the key points section, data on level of evidence (1, 2 and 3) and grade of recommendation (A and B) are given.

Table 1 Levels of evidence. Level of evidence Type of study 1a 1b 2a 2b 3a 3b 4 5 Systematic review of randomized controlled trials with homogeneity Randomized clinical trial with narrow condence interval Systematic review of cohort studies with homogeneity Cohort study or clinical trial of low quality randomization Systematic review of casecontrol studies with homogeneity Casecontrol study Case series or cohort studies and casecontrol low quality Expert opinion without explicit critical appraisal

Centre for Evidence Based Medicine of Oxford (CEBM). Table 2 Grade of recommendation (CEBM). Grade of recommendation A B C D

Level of evidence Level 1 studies Level 23 studies, or extrapolation from level 1 studies Level 4 studies, or extrapolation from level 23 studies Level 5 studies, or inconclusive studies of any levels

Results
Figure 1 reports the overall number of papers identied in the search. Of 1506 identied publications, 823 papers were eligible for review, of which 658 were found to be unsuitable based on the abstract analysis. Thus 165 papers were reviewed. After methodological assessment 73 papers were excluded. Ninety-two papers were nally included in the revision: 57 non-randomized comparative, observational and epidemiological studies, 13 review papers, 10 randomized controlled trials, six national and international guidelines, four case series, one experimental study and one editorial.

Diagnosis and staging of acute diverticulitis

The hydro-soluble contrast enema is not currently in use because the extramural component of inammation is more important than the intramural inammation for the staging of acute diverticulitis. In retrospective studies a

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Treatment of acute colonic diverticulitis

Table 3 Classication of acute diverticulitis by CT criteria.

1506 potentially publications identified from the search 683 excluded as did not meet inclusion criteria 823 abstract reviewed and considered for inclusion 658 abstracts excluded because not meet inclusion criteria 165 relevant full papers considered 73 papers excluded after methodolgical assessment 92 papers included in the final review

Moderate Thickening of the colonic wall Inammation of the pericolonic fat Hypervascularity Oedema

Severe Free air Pericolic abscess or remote abscess Stenosis Extravasation of contrast Diffuse peritonitis

Figure 1 Inclusion of papers from the published reports search.

sensitivity of 6294% has been found [12]. One prospective study comparing hydro-soluble enema and computed tomography (CT) showed CT to be signicantly superior in terms of sensitivity (98% vs 92%, P < 0.01) and evaluation of the severity of inammation (26% vs 9%, P < 0.02) [13]. Abdominal ultrasound is an operator-dependent study that can be difcult in obese patients. The localized smallbowel ileus adjacent to the inammatory process, the presence of gas, interposition of the distal sigmoid colon, pain and rebound tenderness can limit ultrasound evaluation. In prospective studies, it obtains a mean sensitivity and specicity of 91% and 96% [14]. In severely ill patients, it can be used as a rst option diagnostic tool as it avoids the use of intravenous and intraluminal contrast. CT associated with the use of intravenous and oral contrast and, in ideal conditions, rectal contrast is the diagnostic method of choice. CT is useful for differential diagnosis because the tissue density, vascular ingurgitation and oedema of the mesentery are associated with diverticulitis, while the presence of an intraluminal mass and lymph nodes are more associated with the diagnosis of cancer (Level 3b evidence, Grade B recommendation). However, misdiagnosing diverticulitis in cancer patients occurs in 5% of cases. A prospective study found a sensitivity of 97%, specicity of 98% and global accuracy of 98%. It identied localized perforation and abscesses with a sensitivity of 100% and specicity of 91% [15]. Another prospective study [16] showed the capacity of CT to reliably predict the possibility of failure of conservative treatment and the risk of complications. It

classied diverticulitis into two groups (Table 3), moderate when there was a thickening of the colonic wall of more than 4 mm and signs of inammation of the pericolonic fat, and severe when a pericolonic abscess, free air or extravasation of contrast were found. CT can rule out complications and has prognostic value for relapse and for response to medical therapy. It also offers the possibility of percutaneous drainage of abscesses [1618] (Level 2a evidence, Grade B recommendation). Magnetic resonance imaging (MRI) requires a prolonged examination time that can make cooperation of acutely ill patients difcult and is not as sensitive for the identication of free air. In a recent retrospective study MRI showed a sensitivity of 94% and a specicity of 87% [19]. At present there is not enough evidence on the advantages of MRI in the evaluation of acute diverticulitis (Level 4 evidence, Grade C recommendation). Colonoscopy is not recommended in the acute phase because of the risk of perforation. A sigmoidoscopy with low pressure can be performed if there is high suspicion of inammatory bowel disease, ischaemic colitis or cancer. A recent prospective study concluded that although colonoscopy is possible it is rarely needed in the acute phase of inammation [20].

Treatment of diverticulitis
Outpatient treatment

uncomplicated

acute

In 80% of patients with a mild episode of AD a phlegmon in the pericolonic fat with regional mesenteric reaction is observed. The possibility of an outpatient treatment in uncomplicated cases of acute diverticulitis is conditioned by an accurate diagnosis and staging, the general condition of the patient, tolerance to oral intake, possibility of outpatient follow-up, patient collaboration and adequate social support. Treatment consists of oral antibiotics with adequate coverage of Gram-negative and anaerobic pathogens. If symptoms persist or worsen, the patient should be admitted for inpatient treatment. Outpatient

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treatment has also been successful in patients with a pericolonic abscess of < 2 cm [21,22] (Level 3b evidence, Grade B recommendation). After an acute episode and complete resolution of the inammatory process, a colonoscopy should be performed to rule out other diagnosis, especially cancer [20].
Inpatient treatment

Patients with severe AD who do not need emergency surgery should be treated with hospitalization, parenteral uids and a single intravenous antibiotic active against aerobic and anaerobic bacteria [23,24]. In cases of mild AD, criteria for inpatient treatment include the presence of signicant inammation, intolerance to oral uids, age over 8085 years, and patients with immunosuppression or comorbidities (diabetes, chronic renal failure, malignant haematological diseases, HIV, chemotherapy, steroid therapy, transplant patients). The vast majority of patients with mild AD respond to initial medical treatment [25] (Level 3a evidence, Grade B recommendation) and are treated effectively with oral or intravenous antibiotics. A short hospital stay is therefore a safe option [26,27] (Level 2b evidence, Grade B recommendation).
Treatment after an acute episode

diverticulitis during the follow-up. The use of rifaximin and bre supplements improves symptoms in symptomatic diverticular disease but has not proved to be protective against recurrence of acute diverticulitis (Level 2b evidence, Grade C recommendation). Tursi et al. [3436] reviewed the efcacy of mesalazine and the association of mesalazine and probiotic agents for the treatment of chronic diverticular disease with very favourable results in the prevention of symptom recurrence, although with a low grade of recommendation (Level 2b evidence, Grade C recommendation).
Elective surgical treatment

Traditionally, a bre-rich diet has been considered a protective factor in the development of diverticular disease. However, several randomized studies have been inconclusive [28,29], in contrast to previous retrospective studies, on the effect of a bre-rich diet on symptomatic recurrence [30]. Further studies with a higher level of evidence are required to recommend bre as a treatment to prevent recurrence (Level 4 evidence, Grade D recommendation). The chronic inammation is due to an alteration of the normal microora. This has led to the study of antiinfectious, anti-inammatory and probiotic drugs for the medical treatment of patients with symptomatic diverticular disease in order to evaluate their possible preventive effect on symptoms and further episodes of acute diverticulitis [31]. In a prospective randomized controlled trial of patients with uncomplicated diverticular disease, the use of rifaximin increased the proportion of asymptomatic or only mildly symptomatic patients after 12 months of treatment (69% with rifaximin vs 39% with placebo; P = 0.001) [32]. Another study compared the use of bre and rifaximin vs only bre, and the rst group had a signicant improvement in symptoms [33]. In both studies, 2% of patients presented with an episode of acute

The Practice Parameters of the main National and International Associations of Colorectal Surgery recommended elective surgery after two episodes of uncomplicated AD or after one episode in young patients [American Society of Colon and Rectal Surgeons (ASCRS), American College of Gastroenterology, European Association for Endoscopic Surgery (EAES), Aso n Espan ola de Cirujanos] [12,3741]. These ciacio recommendations have been questioned in two important publications [42,43] and are no longer included in the new edition of the Practice Parameters of the ASCRS from 2006 [44]. The recommendation of elective surgery after a favourable response to conservative treatment should be made on an individual basis [45], although some still recommend elective resection after one episode of complicated AD with favourable response to conservative treatment (Level 3a evidence, Grade B recommenkela et al. [46] published in 2010 a revision dation). Ma of 977 patients admitted to hospital for AD in 20 years and concluded that two or more episodes of AD do not justify elective surgery. Mortality of elective surgery increases with age and, on occasion, surgery is not the nal cure of the diverticular disease. Approximately 2733% of patients continue to be symptomatic after surgery and 110% present with a new episode of AD that may require surgery in around 1% of cases [4143]. These last statistics, however, have decreased since it has become accepted that the anastomosis must be performed on the healthy upper rectum [47,48]. The vast majority of patients who need emergency surgery do not have a prior history of diverticular disease and therefore it is questionable that elective surgery would decrease mortality [43,49,50] (Level 2b evidence, Grade B recommendation). After a rst episode of AD, there is a higher risk of death from other diseases than from complications related to the diverticular disease. In one study with 1 year follow-up of patients with uncomplicated AD, 5% presented with a further episode but none of them required surgery [50].

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Treatment of acute colonic diverticulitis

In a prospective multicentre study, 32.5% of patients had severe complications and 25% of them died [41]. In a retrospective study [51], Sarin et al. found that the relapse rate of AD was 2% per patient per year of followup. In another recent retrospective study, it was found that up to 48% of patients with AD treated by conservative means can have a recurrence after more than 10 years of follow-up. Nevertheless the indication for surgery should not only be based on the number of episodes of AD but also on the complications caused by the acute episodes (stenosis, stula or diverticular bleeding) and the risk of suffering another severe episode of AD [52] (Level 2b evidence, Grade B recommendation). Elective surgery is recommended in patients with pelvic abscesses treated by percutaneous drainage due to the poor long-term results after conservative management. However, mesocolic abscesses that resolve with medical treatment are not an absolute indication for subsequent surgery [53] (Level 3b evidence, Grade B recommendation). Salem et al. [42] performed a decision analysis and cost simulation of the clinical and economical results after recovery of an episode of AD treated without surgery. The authors concluded that resection after a fourth episode instead of after a second episode in patients over 50 years of age resulted in 0.5% fewer deaths, 0.7% fewer colostomies and a signicant reduction in costs per patient. The same group [54], in a retrospective study, concluded that less than 10% of patients who recovered after an episode of uncomplicated diverticulitis required a colectomy. It is not clear if young patients have a higher risk of complications or recurrent episodes [43,53,5557]. In the study by Salem et al. [50], 75% of patients did not have recurrences and, of those who did, the majority responded to conservative treatment. In patients younger than 50 years of age, the recurrence rate was 7.5%, and therefore elective surgery does not seem to be indicated after a rst episode of AD. Indication for surgery should consider severity criteria or comorbidities prior to age of the patient [58]. Greenberg et al., in a retrospective study of 149 patients under 40 years of age, found that 55% of patients with initial conservative treatment recurred during a mean follow-up of 5.72 years (62% were never operated on). Of the patients who underwent surgery initially, 15% had a new episode of AD but none of them required surgery [59]. Elective surgery should be indicated to alleviate symptoms and not to prevent deaths due to complications [60]. There is little evidence on the natural history of the disease in immunosuppressed patients. It has been widely accepted that, in these patients, elective surgery should be performed after a single episode of diverticulitis, but there

is no scientic evidence and recommendations are outdated, and all published studies are retrospective small series [61,62]. In a recent systematic review, only 25 studies between 1970 and 2009 were found including patients with AD and a transplant or chronic infections and steroid therapy [63]. None of these studies conrmed that the recurrence of AD after initial medical treatment was severe. The authors concluded that, due to the lack of evidence, a prophylactic sigmoidectomy is not recommended in immunosuppressed patients after one episode of AD.
Elective laparoscopic surgery

The laparoscopic approach has been commonly used in recent years although the inammatory process can make it technically difcult. In a multicentre study of patients operated on for diverticulitis, the rates of complications, conversion and morbidity were acceptable [64] (Level 3b evidence, Grade B recommendation). One prospective study comparing laparoscopic vs open surgery for uncomplicated diverticulitis found less blood loss, earlier return of bowel function, less hospital stay and cost, with a longer operating time and a conversion rate of 19.7% [65]. In a prospective multicentre study [66], higher morbidity was found in the open surgery group, with longer hospital stay, conversion rate of 15.3% with similar operating times and blood loss. Both studies were non-randomized, and the staging of the disease was not reported, and therefore the groups were probably not homogeneous. A recent prospective study reported a conversion rate of 6.8%, total complication rate of 18.4%, anastomotic leak 1.6% and mortality 0.5% [67]. In 1999, the EAES concluded that laparoscopic resection is recommended in uncomplicated cases and after abscess drainage [38]. In 2003, the American Society of Gastrointestinal Endoscopic Surgery recommended that laparoscopic surgery is adequate in uncomplicated diverticulitis and the benets depend on a low conversion rate. In complicated diverticulitis a laparoscopic approach may be difcult and inappropriate [68]. In a review of eight studies on laparoscopic surgery for complicated acute diverticulitis, reporting cases between 1990 and 2008, a conversion rate of 3% was described, with a 10% rate of complications. In 38% of operations a primary anastomosis was performed [69]. A laparoscopic approach in diverticulitis is appropriate but can be technically complex and requires experience in laparoscopic surgery; the benets will mostly depend on low conversion and morbidity rates. After three or more episodes of AD the technical difculty increases and the risk of conversion and postoperative complications

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increases [7075] (Level 3b evidence, Grade B recommendation).

Table 5 Mannheim peritonitis index. Risk factor Score 5 5 7 4 4 4 6 0 6 12

Complicated peritonitis

acute

diverticulitis

with

Diagnosis, staging and prognostic factors for mortality

Diverticulitis is the most common cause of colonic perforation and represents 60% of all cases. Approximately 1020% of patients admitted for acute diverticulitis will require emergency surgery [55]. Hincheys classication subdivides the peritonitis into four stages (Table 4) according to the operative ndings. This classication has been extrapolated to CT ndings and has been proved to be useful to stage the extension of the inammatoryinfectious process [76]. In immunocompromised patients, the consequences of a colonic perforation tend to be more severe [77,78]. A patient is considered immunosuppressed when there is a prior history of steroid therapy, extracolonic neoplasia present at the time of diagnosis of AD, chemotherapy, malnutrition (weight loss over 10% of the body mass index in the previous 2 months), or congenital or acquired immunosuppression [79]. The increase in the number of transplants, the AIDS epidemic and the chronic use of steroids for different diseases has increased the population of immunocompromised patients. Different classications are used to study prognostic factors for postoperative mortality. The Acute Physiologic and Chronic Health Evaluation (APACHE) II provides a good correlation between mortality rate and severity of the disease [80]. It is not a specic index for peritonitis and it does not contemplate the prognostic signicance of factors such as the characteristics and the origin of the peritonitis. The Mannheim Peritonitis Index (MPI) [80] is a classication system that is applicable to peritonitis of any aetiology and is effective in predicting the risk of postoperative mortality (Table 5). The main advantages of the classication are due to the fact that each variable can be calculated in routine clinical conditions, quickly, without any technical assistance and it is only registered at the time of the surgery facilitating its use [81].

Age > 50 years Female Preoperative organ failure Malignancy Preoperative duration of peritonitis > 24 h Origin of sepsis not colonic Generalized faecal peritonitis Exudates Clear Purulent Faecal

The Peritonitis Severity Score (PSS) is specic for left colonic perforation and is based on objective physicopathological and surgical data [82] (Table 6). It was observed that all the variables studied were associated with higher postoperative mortality, but in the multivariate analysis only the American Society of Anesthesiologists (ASA) grade and preoperative organ failure had a statistically signicant higher prognostic signicance for mortality. The study concluded that the identication of risk factors for postoperative mortality and an early evaluation of the mortality risk of the patient could be useful to modulate the aggressiveness of the surgical strategy for left colonic peritonitis. The PSS and MPI have been compared and both systems are predictive of mortality in left colonic perforation [83] (Level 3b evidence, Grade B recommendation). The choice of surgical technique seems to have only a partial inuence on the outcome. Zeitoun et al., [84] in a multicentre randomized controlled trial, observed that there were no signicant differences in mortality between patients with diffuse peritonitis due to perforated sigmoid diverticulitis treated with primary resection or colostomy and drainage. The surgical alternatives in emergency surgery for left colonic disease are still a matter of debate.

Table 6 Peritonitis severity score. Score 1 70 III No No No 12 2 > 70 III Yes Yes 34 3 IV One or more

Table 4 Hinchey classication of the grade of peritonitis. Grade I Grade II Grade III Grade IV Inammation of the pericolonic fat or pericolic abscess Pelvic or distant abscess Generalized purulent peritonitis Generalized faecal peritonitis

Age (years) ASA grade Preoperative organ failure Immunosuppression Ischaemic colitis Grade of peritonitis

ASA, American Society of Anesthesiologists.

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Treatment of acute colonic diverticulitis

Several studies have shown an increased survival in patients treated with primary resection and anastomosis compared with those treated with three-stage surgery [8487]. At present there is a trend towards performing primary anastomosis in selected patients [88].
Treatment of diverticular abscess

Small sized abscesses respond to treatment with intravenous antibiotics. When the abscess diameter is over 5 cm, percutaneous CT guided drainage, in combination with antibiotics, is the standard treatment and offers rapid improvement in symptoms in over 90% of cases, albeit with a high recurrence rate in more severe cases [76].
Surgical treatment of complicated acute diverticulitis

Hartmanns procedure in complicated acute diverticulitis has been the standard technique in emergency surgery with satisfactory results and a mortality rate that varies between 2.6% and 7.3% [85]. However, bowel reconstruction after Hartmanns procedure requires a new laparotomy and a high percentage of patients will not undergo further surgery due to other medical problems, therefore remaining with a permanent stoma. Although a recent study showed that Hartmanns reconstruction can be performed laparoscopically and is associated with a faster return of bowel function and a shorter hospital stay in comparison with a series of open Hartmanns reconstruction, randomized studies will be needed to determine if laparoscopic Hartmanns reconstruction is superior to the conventional technique [86,87]. Hartmanns technique could be relegated to cases of severe AD with peritonitis in patients with poor prognostic criteria, while resection with primary anastomosis and peritoneal lavage will be the technique of choice in selected patients [88] (Level 3a evidence, Grade B recommendation). The ideal therapeutic option in left colonic perforation is one-stage procedure with primary anastomosis. This option adds the benet of being a denitive treatment and avoids the morbidity and mortality associated with a stoma and its reconstruction [87]. Lee et al. [87] showed that resection, intraoperative lavage of the colon and primary anastomosis in emergency surgery for complicated diverticulitis is a safe procedure, although they recommended Hartmanns procedure in cases of diffuse or faecal peritonitis, immunocompromised patients or septic shock with multiorgan failure (Level 3b evidence, Grade B recommendation). In a recent study, it has been observed that a primary anastomosis can be performed safely in the presence of

localized or diffuse peritonitis in selected patients [89]. Primary anastomosis is contraindicated in faecal peritonitis, septic shock, haemodynamic instability, chronic steroid therapy and poor condition of the patient. Recently, obesity was added to the possible contraindications [8791]. A protective ileostomy after resection and primary anastomosis could be a valid alternative in high risk patients (immunosuppression, ASA grade IV, faecal peritonitis) with perioperative haemodynamic stability, after technical difculties, or in extraperitoneal anastomosis. In a recent review of the literature, it has been observed that the rates of anastomotic leak and wound infection in patients treated with resection and primary anastomosis for peritonitis due to diverticular perforation is lower when a protective ileostomy is associated [91]. Recent publications have shown that an emergency segmental colonic resection with primary anastomosis with or without bowel preparation can be performed with positive results [9294].
Laparoscopy in emergency surgery for perforated diverticulitis

Laparoscopic peritoneal lavage has been used as a safe alternative in the management of perforated diverticulitis with diffuse purulent peritonitis [71]. There have been case series published and prospective studies that have shown benets compared with conventional management [72 75]. It achieves a lower mortality rate and stoma formation rate, less wound infection and less operating time, and no signicant differences were found with respect to recurrence rates compared with resection and primary anastomosis. But even though there is some available evidence, the lack of prospective clinical trials, with the exception of the study published by Myers et al. [73], has limited the widespread use of laparoscopic lavage. There have been cases published of unnecessary laparoscopy, such as in pelvic abscesses that could have been drained percutaneously, or cases of diffuse peritonitis treated only with lavage of the peritoneal cavity without following the principles of surgical treatment of acute peritonitis. It has been proved that immediate resection has much more favourable results than colostomy and drains in perforated colonic diverticulitis [73,75,76,79].

Conclusions
The prevalence of diverticular disease is a rst class healthcare problem in developed countries and causes signicant morbidity and mortality. The heterogeneity of patients means that both elective and urgent treatment

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should be tailored on an individual basis. Further studies are needed to improve the level of evidence and grade of recommendation on different aspects of acute diverticulitis.

Key points
1 An abdominal CT is the most effective tool for diagnosis and staging of AD, and can also be used for percutaneous drainage of abscesses. 2 In patients without signicant comorbidities and an uncomplicated diverticulitis, outpatient treatment can be performed. 3 Conservative treatment can be used for patients with uncomplicated AD, small abscesses or percutaneously drained abscesses. 4 The recommendation of elective surgery after a favourable response to medical treatment should be made on an individual basis. Elective laparoscopic surgery in diverticulitis is appropriate but is technically complex and requires experience in laparoscopic surgery. 5 The PSS scoring system is a specic system for peritonitis of colonic origin that helps to predict mortality and is useful in the decision making process. 6 In cases of perforated diverticulitis, after a careful selection of patients, the technique of choice should be resection with primary anastomosis. However, at present, laparoscopic lavage is being considered as a potentially safe alternative in cases of purulent peritonitis.

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Acknowledgement
This study was supported by FIS grant number PI080989 from the Carlos III Institute, Ministry of Science and Innovation, Spain.

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References
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