Acute diverticulitis management: evolving trends among Italian surgeons. A survey of the Italian Society of Colorectal Surgery (SICCR)

Abstract

Acute diverticulitis (AD) is associated with relevant morbidity/mortality and is increasing worldwide, thus becoming a major issue for national health systems. AD may be challenging, as clinical relevance varies widely, ranging from asymptomatic picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications, and management. A 33-item-questionnaire was administered to residents and surgeons to analyze the actual clinical practice and to verify the real spread of recent recommendations, also by stratifying surgeons by experience. CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age. Outpatient management of mild AD is slowly gaining acceptance. A conservative management is preferred in non-severe cases with extradigestive air or small/non-radiologically drainable abscesses. In severe cases, a laparoscopic approach is preferred, with a non-negligible number of surgeons confident in performing emergency complex procedures. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is spreading in life-threatening cases. Quality of life and history of complicated AD are the main indications for delayed colectomy, which is mostly performed avoiding the proximal vessel ligation, mobilizing the splenic flexure and performing a colorectal anastomosis. ICG is spreading to check anastomotic stumps' vascularization. Differences between the two experience groups were found about the type of investigation to exclude colon cancer (considering the experience only in terms of number of colectomies performed), the size of the peritoneal abscess to be drained, practice of damage control surgery and the attitude towards colovesical fistula.

Keywords: Acute diverticulitis; Diagnosis; Management; Surgery.

Fig. 1

Modified Hinchey classification by Wasvary et al. based on CT findings. CT computed tomography, AD acute diverticulitis

Fig. 2

Type of hospital. Distribution of the various hospital settings among the respondents

Fig. 3

No. of colectomies (unit) per year. Surgical activity in terms of numbers of colectomies performed per year in the respondents' centers

Fig. 4

Personal experience (years). Years of experience among the respondents

Fig. 5

Surgeon’s experience. Number of colectomies performed among respondents

Fig. 6

Percentage of Hartmann’s resections/total emergency procedures for AD. Frequency of Hartmann procedures in the centers where respondents work