From the Guidelines
Management of microperforation associated with diverticulitis typically requires a damage control surgical strategy with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforation. This approach is based on the most recent evidence from the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1. The initial surgery focuses on control of the sepsis, and a subsequent operation deals with the anatomical restoration of the gastrointestinal tract, after a period of physiological resuscitation.
Key considerations in the management of microperforation associated with diverticulitis include:
- Prompt emergency operation for generalized diverticular peritonitis, a life-threatening condition requiring immediate attention
- Use of a damage control surgical strategy with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforation
- Initial surgery limited to source control, e.g., primary closure of the perforation/local resection of the diseased bowel, followed by physiologic optimization in the intensive care unit (ICU)
- Delayed bowel anastomosis to a period of physiological stability, potentially favoring a primary anastomosis and avoiding the formation of a stoma altogether
The evidence supporting this approach includes a prospective observational study by Kafka-Ritsch et al. 1, which demonstrated that bowel continuity was restored in 84% of patients, with an overall mortality rate of 9.8%. Additionally, a case-control study by Sohn et al. 1 showed that the damage control strategy was associated with a significant reduction in stoma creation, without differences in morbidity and mortality.
In contrast, percutaneous catheter drainage (PCD) may be considered for larger collections, with reported efficacy ranging from 70% to 90% 1. However, this approach is not directly applicable to the management of microperforation associated with diverticulitis, and the primary focus should remain on prompt surgical intervention and damage control strategies.
From the Research
Management of Microperforation Associated with Diverticulitis
The management of microperforation associated with diverticulitis can be approached in several ways, depending on the severity of the condition and the patient's overall health.
- Conservative management with broad-spectrum antibiotics and total parenteral nutrition may be suitable for patients in good condition with no septic signs 2.
- Non-operative treatment can be 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 3.
- The decision to operate is not based on the presence of extraluminal air, but rather on the presence of diffuse peritonitis or failure of conservative management 4.
Surgical Management
Surgical management may be necessary in cases of perforated diverticulitis with generalized peritonitis or failure of conservative management.
- Emergency laparoscopy has benefits over open surgery in hemodynamically stable patients 4.
- Options for surgical management include resection and anastomosis, Hartmann's procedure, or laparoscopic lavage 5, 4, 6.
- In cases of generalized peritonitis with septic shock, an open surgical approach is preferred, with non-restorative resection and/or damage control surgery as viable options 4.
Factors Influencing Management
Several factors can influence the management of microperforation associated with diverticulitis, including:
- Severity of the condition, with more severe cases requiring surgical intervention 3, 4.
- Patient's overall health, with comorbidities and immune status playing a role in the decision-making process 4.
- Presence of abscess or pneumoperitoneum, which may require guided percutaneous drainage or surgical intervention 5, 6.