What is the treatment for diverticular perforation?

Treatment of Diverticular Perforation

For diverticular perforation with diffuse peritonitis, immediate surgical intervention with Hartmann's procedure is the standard of care in hemodynamically unstable patients or those with significant comorbidities, while primary resection with anastomosis should be performed in stable patients without major comorbidities. 1, 2

Immediate Management Algorithm

Resuscitation and Antibiotics

• Initiate aggressive fluid resuscitation, hemodynamic monitoring, and broad-spectrum intravenous antibiotics immediately upon diagnosis 1, 2
• Antibiotic options include meropenem, doripenem, imipenem/cilastatin, or eravacycline, covering anaerobes and gram-negative organisms 3
• Continue antibiotics for 3-5 days post-operatively in immunocompetent patients with adequate source control, or 7 days in immunocompromised or critically ill patients 2, 3

Surgical Decision-Making Based on Clinical Presentation

Diffuse Peritonitis (Most Common Scenario)

• Hemodynamically unstable patients or multiple comorbidities: Hartmann's procedure is mandatory 1, 2, 3
• Hemodynamically stable patients without major comorbidities: Primary resection with anastomosis results in 40% lower mortality compared to Hartmann's procedure 2
• Emergency laparoscopic sigmoidectomy can be performed in stable patients with conversion rates of 0-19% 2
• Consider protecting the anastomosis with diverting loop ileostomy in borderline cases 2

Distant Free Gas WITHOUT Diffuse Peritonitis (Highly Selected Cases)

• Non-operative management may be attempted only in hemodynamically stable patients with small amounts of distant free gas, absence of clinical diffuse peritonitis, and no fluid in the fossa of Douglas 1
• Success rate is 94% for pericolic free air but drops to 71.4% for distant free air 4
• Large amounts of distant intraperitoneal gas or distant retroperitoneal gas are associated with 57-60% failure rates of conservative management 1, 3
• Close clinical and CT monitoring is mandatory, as approximately 14.6% of patients will fail non-operative treatment and require emergency surgery 4

Critical Pitfalls to Avoid

• Never perform primary anastomosis in unstable patients or those with fecal peritonitis, as this significantly increases mortality 3
• Do not rely on laparoscopic lavage as definitive treatment for diffuse peritonitis—it is not considered first-line treatment and has unacceptably high reoperation rates 1, 3
• Do not attempt non-operative management in patients with large amounts of distant free gas or clinical peritonitis, as failure rates approach 60% 1, 3
• Avoid assuming all perforations require immediate surgery—highly selected stable patients with pericolic gas only may be managed conservatively with close monitoring 1, 4

Damage Control Surgery for Physiological Extremis

If the patient is in physiological extremis or hemodynamically unstable despite resuscitation:

• Perform limited resection or closure of perforation with peritoneal lavage and drainage 3
• Use temporary abdominal closure 3
• Plan ICU resuscitation followed by second-look operation for bowel reconstruction 3

Abscess Management

• Abscesses associated with perforation require source control through surgical intervention 3
• In stable patients with localized abscess and minimal free air, percutaneous drainage combined with antibiotics may be attempted before proceeding to surgery 4