This document summarizes guidelines for diverticulitis and recent updates. It discusses that the prevalence of diverticulosis is increasing compared to past centuries. About 20% of patients with diverticulosis will develop diverticulitis in their lifetime. For initial evaluation of acute diverticulitis, CT scan is the imaging of choice. Medical treatment typically involves antibiotics and diet modification. The decision to perform elective surgery after acute uncomplicated diverticulitis should be individualized. Emergency surgery is required for patients with diffuse peritonitis or treatment failure with non-operative management.

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Diverticulosis Guidelines and
Recent Updates

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• Prevalance is increasing compared to past century
• ~ 20% of patients with diverticulosis develop diverticulitis over the
course of their lifetime

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Initial evaluation – Acute Diverticulitis
• Problem-specific history and physical examination
• Complete blood count, urinalysis, and abdominal radiographs in
selected clinical scenarios
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
• CT scan of the abdomen and pelvis is the IOC
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.

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• Ultrasound and MRI can be useful alternatives in the initial evaluation
of a patient with suspected acute diverticulitis
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

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Medical Treatment of Acute Diverticulitis
• Nonoperative treatment typically includes oral or intravenous
antibiotics and diet modification.
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C
• Image-guided percutaneous drainage is usually the most appropriate
treatment for stable patients with large diverticular abscesses.
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

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Elective Surgery for Acute Diverticulitis
• The decision to recommend elective sigmoid colectomy after recovery
from uncomplicated acute diverticulitis should be individualized.
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B
• Elective colectomy should typically be considered after the patient
recovers from an episode of complicated diverticulitis
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B

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• Routine elective resection based on young age (<50 years) is no
longer recommended
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.

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Emergency Surgery for Acute Diverticulitis
• Urgent sigmoid colectomy is required for patients with diffuse
peritonitis or for those in whom nonoperative management of acute
diverticulitis fails
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B
• Following resection, the decision to restore bowel continuity must
incorporate patient factors, intraoperative factors, and surgeon
preference.
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

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• In patients with purulent or feculent peritonitis, operative therapy
without resection is generally not an appropriate alternative to
colectomy.
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

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Technical Considerations
• The extent of elective resection should include the entire sigmoid
colon with margins of healthy colon and rectum
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C
• When expertise is available, the laparoscopic approach to elective
colectomy for diverticulitis is preferred
• Grade of Recommendation: Strong recommendation based on high-quality evidence, 1A

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• A leak test of the colorectal anastomosis should be performed during
surgery for sigmoid diverticulitis
• Grade of Recommendation: Strong recommendation based on low-quality evidence 1C
• Ureteral stents are used at the discretion of the surgeon
• Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C

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• Oral mechanical bowel preparation is not required; however, the use
of oral antibiotics may decrease surgical site infections after elective
colon resection
• Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B
• Elective colectomy for diverticulitis may be performed by sparing the
superior hemorrhoidal artery or according to cancer surgery
principles
• Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C

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• Observational studies with unmatched patients were the best
available evidence which limited comparability and resulted in risk of
selection bias and confounding by indication
• Diverticular abscesses with diameters less than 3 cm might be
sufficiently treated with antibiotics, while the best treatment for
larger abscesses remains uncertain
• Acute surgery should be reserved for critically ill patients failing non-
operative treatment
• Further research is needed to determine the best treatment for
different sizes and types of diverticular abscesses, preferably
randomized controlled trials

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• Results
• Primary resection with anastomosis has a significant advantage in
terms of lower mortality rate with respect to Hartmann’s procedure
(P00.02).
• The postoperative length of hospitalization was significantly shorter in
the resection with anastomosis group (P<0.001).
• Different findings have emerged from studies of patients with the
primary resection with anastomosis vs laparoscopic peritoneal lavage
and subsequent resection:
• overall surgical morbidity and hospital stay were lower in the
laparoscopic peritoneal lavage group compared to the primary
resection and anastomosis group (P<0.001).

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• Conclusions
• Despite numerous published articles on operative treatments for
patients with generalized peritonitis from perforated diverticulitis, we
found a marked heterogeneity between included studies limiting the
possibility to summarize in a metanalytical method the data provided
and make difficult to synthesize data in a quantitative fashion.
• The advantages in the group of colon resection with primary
anastomosis in terms of lower mortality rate and postoperative stay
should be interpreted with caution because of several limitations.
• Future randomized controlled trials are needed to further evaluate
different surgical treatments for patients with generalized peritonitis
from perforated diverticulitis.

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• Accumulated empirical experience during the last two decades shows that laparoscopy is
undeniably a promising adjunct in the management of complicated colonic diverticulitis
• Analysis of presently available data also highlights the urge to build largescale
prospective RCTs in order to elucidate the exact benefits of laparoscopy and to define
patients who are the best candidates for each approach
• Like the ongoing trials NCT01019239 (IRISH) and NCT01047462 (SCANDIV), solid data are
particularly awaited in order to clarify the exact place of LLD and to determine the most
appropriate sigmoid resection procedure (laparoscopic HP or RPA) in Hinchey 3 and 4
peritonitis.
• The advantages provided by laparoscopy in chronic complications of diverticulitis and HP
reversal also need to be confirmed
• In the absence of precise recommendations, we suggest the following algorithm that
may assist general surgeons in their decision-making when dealing with complicated
colonic diverticulitis (Figure 1).

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• Multicenter, randomized clinical superiority trial recruiting
participants from 21 centers in Sweden and Norway from February
2010to June 2014.
• The last patient follow-up was in December 2014 and final review and
verification of the medical records was assessed in March 2015
• Patients with suspected perforated diverticulitis, a clinical indication
for emergency surgery, and free air on an abdominal computed
tomography scanwere eligible
• Of 509 patients screened, 415 were eligible and 199 were enrolled.

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• Assigned to undergo laparoscopic peritoneal lavage (n = 101) or colon
resection (n = 98) based on a computer-generated, center-stratified
block randomization
• All patients with fecal peritonitis (15 patients in the laparoscopic
peritoneal lavage group vs 13 in the colon resection group)
underwent colon resection
• Patients with a pathology requiring treatment beyond that necessary
for perforated diverticulitis (12 in the laparoscopic lavage group vs 13
in the colon resection group) were also excluded from the protocol
operations and treated as required for the pathology encountered

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• RESULTS
• The primary outcome - severe postoperative complications (Clavien-Dindo score >IIIa) within 90
days
• 31 of 101 patients (30.7%) in the laparoscopic lavage group
• 25 of 96 patients (26.0%) in the colon resection group (difference, 4.7% [95%CI, −7.9%to 17.0%]; P = .53).
• Mortality at 90 days did not significantly differ
• Laparoscopic lavage group (14 patients [13.9%]) and the colon resection group (11 patients [11.5%];
difference, 2.4%[95%CI, −7.2%to 11.9%]; P = .67).
• The reoperation rate was significantly higher
• Laparoscopic lavage group (15 of 74 patients [20.3%])
• Colon resection group (4 of 70 patients [5.7%]; difference, 14.6%[95%CI, 3.5%to 25.6%];P = .01) for patients
who did not have fecal peritonitis.
• The length of operating time was significantly shorter in the laparoscopic lavage group
• Length of postoperative hospital stay and quality of life did not differ significantly between groups
• Four sigmoid carcinomas were missed with laparoscopic lavage

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• CONCLUSIONS AND RELEVANCE
• Among patients with likely perforated diverticulitis and undergoing
emergency surgery, the use of laparoscopic lavage vs primary
resection did not reduce severe postoperative complications and led
to worse outcomes in secondary end points
• These findings do not support laparoscopic lavage for treatment of
perforated diverticulitis

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• The Ladies trial is a multicentre, parallel-group, randomised, open-label superiority
trial done in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and
the Netherlands
• Designed to compare laparoscopic lavage and sigmoidectomy for purulent perforated
diverticulitis in the LOLA group
• To compare Hartmann’s procedure versus sigmoidectomy with primary anastomosis
in both purulent and faecal perforated diverticulitis in the DIVA group
• Patients with signs of general peritonitis and suspected perforated diverticulitis were
eligible for inclusion
• Radiological examination by radiography or a CT scan had to show diffuse-free
intraperitoneal air or fluid for patients to be classified as having perforated
diverticulitis

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• Exclusion criteria
• Dementia, previous sigmoidectomy, pelvic irradiation, chronic treatment with
high-dose steroids (>20 mg daily), being aged younger than 18 years or older
than 85 years, and having preoperative shock needing inotropic support,
Hinchey I and II perforated diverticulitis
• Patients with Hinchey IV peritonitis or overt perforation could only be
included in the DIVA group
• Diagnostic laparoscopy was done to confirm the diagnosis of
perforated diverticulitis
• Distinguish between purulent and faecal peritonitis or overt
perforation

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• Only patients with purulent perforated diverticulitis without overt perforation were
randomly assigned within the LOLA group with secure online computer
randomization
• Patients were randomly assigned (2:1:1) to receive either
• Laparoscopic lavage,
• Sigmoidectomy without primary anastomosis, or
• Sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy)
• Allowing for a 1:1 comparison between lavage and sigmoidectomy in the LOLA
group
• Patients with an overt perforation or faecal peritonitis were included in the DIVA
group of the study and not analysed within the LOLA group

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• The DIVA section of this trial is still underway
• Results of the LOLA section
• Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA
section of the Ladies trial
• The study was terminated by the data and safety monitoring board because of an increased
event rate in the lavage group
• Two patients were excluded for protocol violations
• The primary endpoint major morbidity and mortality within 12 months
• 30 (67%) of 45 patients in the lavage group
• 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54–3·03, p=0·58)
• By 12 months, 4 patients died after lavage and 6 patients died after sigmoidectomy (p=0·43)

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• First randomised trial to report the long-term results of laparoscopic
lavage and sigmoidectomy for purulent perforated diverticulitis.
• The trial was stopped early at 33% of the planned sample size as
advised by the Data Safety Monitoring Board
• High major morbidity and mortality rate in the lavage group
• Despite the promising results of previous case series, the study could
not show superiority of laparoscopic lavage with regard to major
morbidity and mortality
• Failure to properly distinguish Hinchey III from Hinchey IV perforated
diverticulitis and underlying colorectal cancer accounted for most of
the lavage failures
• Improved preoperative diagnostics—eg, CT with rectal contrast might
optimize the results of laparoscopic lavage

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• Laparoscopic lavage was compared with colon resection and stoma in
a randomized controlled multicenter trial, DILALA (ISRCTN82208287)
• Initial diagnostic laparoscopy showing Hinchey III was followed by
randomization
• Clinical data was collected up to 12 weeks postoperatively
• Patients were included at 9 surgical departments in Sweden and
Denmark from February 2010 to February 2014
• 83 were randomized, out of whom 39 patients in laparoscopic lavage
and 36 patients in the Hartmann procedure groups
• Morbidity and mortality after laparoscopic lavage did not differ when
compared with the Hartmann procedure
• Laparoscopic lavage resulted in shorter operating time, shorter time
in the recovery unit, and shorter hospital stay
• Laparoscopic lavage as treatment for patients with perforated
diverticulitis Hinchey III was feasible and safe in the short-term

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• Aim - to compare the results of sigmoid resection with laparoscopic lavage
• Methods - systematic review was performed to select randomized
controlled trials comparing laparoscopic lavage versus resection in Hinchey
III diverticulitis
• LADIES, DILALA, SCANDIV trials included
• In the LADIES and the DILALA trials patients were randomized after the
demonstration of Hinchey III purulent diverticulitis at the diagnostic
laparoscopy
• In SCANDIV trial patients were randomized after the CT scan
• There were also randomized patients with evidence of Hinchey I-II
diverticulitis at laparoscopy
• In all the studies patients with Hinchey IV-fecaloid peritonitis were drop
out from the study and received Hartmann procedure

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• Treatment
• In all studies patients received empiric antibiotic therapy before surgery.
• Laparoscopic lavage was performed with at least 3–4 L of warm saline water.
• After the laparoscopic lavage patients received a colonoscopy after a time
variable between 4 and 12 weeks but routine sigmoidectomy was not
recommended
• In the SCANDIV trial colonic resection was performed in laparoscopy or with
open surgery according to the centre/surgeon’s preference, with or without
primary anastomosis
• in the LADIES trial patients in resection group were further randomized to
receive Hartmann procedure or primary anastomosis
• In the DILALA trial patients randomized to resection all underwent Hartmann
procedure
• All the included patients had an abdominal drain after operation and were
treated according to the local standards

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• Results
• Three RCT were selected for the meta-analysis including 315 patents
• Laparoscopic lavage was associated with significantly
• more reoperations (OR 3.75, p = 0.006)
• more intra-abdominal abscesses (OR 3.50, p = 0.0003)
• no differences in mortality (OR 0.93, p = 0.92)
• At 12 months follow up laparoscopic lavage was associated
• lesser reoperations (OR 0.32, p = 0.0004)
• No differences in term of stoma presence (OR 0.44 p = 0.27) and mortality (OR
0.74 p = 0.51)

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• Conclusions
• The present meta-analysis shows that in acute perforated
diverticulitis with purulent peritonitis laparoscopic lavage is
comparable to sigmoid resection in terms of mortality but it is
associated with a significantly higher rate of reoperations and a
higher rate of intra-abdominal abscess.
• No differences in term of mortality were demonstrated at follow-up.
• Further studies are needed to better define the safety and
appropriateness of this treatment.

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• Purpose
• Compared current guidelines on the disease in order to identify concordant and
discordant recommendations
• Eleven national and international guidelines on diverticular disease
• Last 10 years have been identified by a systematic literature review on
PubMed
• Compared in detail for 20 main and 51 subtopics

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• Results
• The available evidence for the most aspects was rated as moderate or low
• There was concordance for the following items:
• Diagnosis of diverticulitis should be confirmed by imaging methods (10 of
10 guidelines)
• Mild forms may be treated outpatient (10/10)
• Abscesses are treated non-surgically (9/9)
• Elective surgery should be indicated by individual patient-related factors,
only, and be performed laparoscopically (10/10, 9/9 respectively)

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• Main differences were found in the questions of
• Appropriate classification
• imaging diagnostic (computed-tomography versus ultra-sound)
• need for antibiotics in out-patient treatment
• mode of surgery for diverticular perforation
• Despite growing evidence that antibiotics are not needed for treating mild diverticulitis only
3/10 guidelines have corresponding recommendations
• Hartmann’s procedure has been abandoned several years ago and is now recommended for
feculent peritonitis by the three most recent guidelines
• In contrast, laparoscopic lavage without resection is not recommended anymore