What is the management of perforated diverticulitis of the large intestine (colon)?

From the Guidelines

Management of perforated diverticulitis of the large intestine requires prompt surgical intervention, with the initial approach including fluid resuscitation, broad-spectrum antibiotics, and pain management, followed by surgical options such as Hartmann's procedure or primary resection with anastomosis, depending on the severity of peritoneal contamination and patient stability. The most recent and highest quality study, published in 2022 by the World Journal of Emergency Surgery 1, suggests that in elderly patients with perforated diverticulitis and generalized peritonitis, both Hartmann operation and resection with primary anastomosis are reasonable options.

Key Considerations

• The severity of peritoneal contamination and patient stability play a crucial role in determining the surgical approach.
• For stable patients with localized contamination, primary resection with anastomosis may be performed.
• For unstable patients or those with extensive contamination, a Hartmann's procedure is often preferred.
• Laparoscopic lavage and drainage may be considered in select cases of very localized perforation with minimal contamination.

Surgical Options

• Hartmann's procedure: involves sigmoid resection with end colostomy and rectal stump closure.
• Primary resection with anastomosis: may be performed in stable patients with localized contamination.
• Damage control surgery: may be considered in critically ill patients who cannot withstand major surgery.

Postoperative Care

• Antibiotics should be continued for 5-7 days, depending on clinical response.
• The patient should be monitored for complications such as intra-abdominal abscess, wound infection, or anastomotic leak.
• Nutritional support should be initiated early, progressing from clear liquids to a low-residue diet as tolerated.
• After recovery, patients should be counseled on high-fiber diet, adequate hydration, and regular physical activity to prevent recurrence of diverticular disease.

Evidence-Based Recommendations

• The 2022 guidelines from the World Journal of Emergency Surgery 1 provide the most recent and highest quality evidence for the management of perforated diverticulitis.
• The 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1 also provides relevant recommendations.
• The ACR Appropriateness Criteria for radiologic management of infected fluid collections 1 provide guidance on the use of percutaneous catheter drainage.

From the Research

Management Options

The management of perforated diverticulitis of the large intestine (colon) can be approached through various surgical and non-surgical methods, including:

• Hartmann's procedure, which is considered the surgical treatment of choice for perforated diverticulitis 2
• Resection with anastomosis, with or without stoma
• Laparoscopic lavage and drainage, which is a safe alternative to the current standard of treatment and is associated with a decrease in overall cost, avoidance of colostomy, and reduction in mortality and morbidity 3
• Conservative management, which is safe and successful in patients with acute perforated diverticulitis without generalized peritonitis, with a success rate of 94.0% and 71.4% for patients with pericolic and distant free air, respectively 4

Patient Selection

The choice of management approach depends on the patient's condition, including:

• Presence of generalized peritonitis, which requires emergency surgery
• Presence of localized peritonitis, which may be managed conservatively
• Patient's functional and physiological status, with surgical treatments resulting in the best outcomes for patients with good status, and minimally invasive and medical alternatives considered for frailer patients 5
• Presence of co-morbidities, which may affect the choice of management approach

Surgical Techniques

Various surgical techniques can be used to manage perforated diverticulitis, including:

• Hartmann resection, which is a common approach for patients with perforated diverticulitis 6, 2
• Paul-Mikulicz operation, which may be considered for patients with rupture of a single diverticulum 6
• Ideal colectomy, which is considered the best intervention for patients with early presentation and temporary colostomy 6
• Laparoscopic peritoneal lavage and drainage, which is a minimally invasive approach that can alleviate morbidity and improve outcomes 3