Emergency management of diverticulitis

Abstract

The most common indications for emergency operative intervention in the treatment of sigmoid diverticulitis are peritonitis and failure of medical therapy. Primary resection and diversion (Hartmann's procedure) followed by delayed colostomy closure is the current standard of emergency surgical care. Guidelines for best operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. Primary resection and anastomosis with or without proximal diversion and laparoscopic lavage are alternatives to Hartmann's procedure that may provide an improved outcome in properly selected patients. Ongoing changes in the historical paradigm of the surgical approach to this disease mandate the need for large multicentered prospective randomized trials to determine the best surgical strategy under emergent conditions for the treatment of diverticulitis. The current literature is reviewed with suggestions for a management algorithm.

Keywords: Diverticular peritonitis; Hartmann's procedure; anastomosis; diverticulitis; laparoscopic lavage; peritonitis; primary resection.

Figure 1

This proposed algorithm depicts a nominal scale of categories of risk factors to consider in determining the risk of surgical outcome. The categories consist of Severity of Disease, Patient Presenting Physiology, Patient Comorbidities, Hospital/ Situational Factors, and Surgeon Factors. Assignment of a value to each variable within a category is not possible due to the lack of a validated scoring system. However, variables are stratified from low risk for morbidity and mortality to high risk, and should be considered as a guide in the process of deciding operative strategy, with the caution that additional unidentified variables certainly exist, and may play a significant role in outcome. The likelihood of performing Hartmann's procedure is based on accumulation of risk factors and application of surgeon's judgment based on the clinical scenario.