Diagnosis and treatment of acute left colonic diverticulitis in older patients: WSES guidelines
Italy: A recent study in the World Journal of Emergency Surgery reports guidelines for diagnosis and treatment of acute left colonic diverticulitis (ALCD) in the elderly. The guideline was released jointly by the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC).
The paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique, and antibiotic therapy.
When compared with younger patients, ALCD in the elderly presents with unique epidemiological features. In the elderly population, the clinical presentation is more nuanced, having higher in-hospital and postoperative mortality. Also, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients are at a lower risk of recurrent episodes and, in case of recurrence, there is a lower probability of requiring urgent surgery than younger patients.
Paola Fugazzola, IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy, and colleagues, therefore, aimed to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis.
DIAGNOSIS
Could the diagnosis of acute left colonic diverticulitis be based on only clinical signs, symptoms and laboratory test in elderly patients?
Statement 1.1 In the elderly population, the authors suggest against basing the diagnosis of acute left colonic diverticulitis on only patient clinical signs, symptoms, and laboratory tests.
Statement 1.2 The authors suggest that elderly patients presenting with abdominal guarding or pain in the lower left abdomen on physical examination undergo appropriate imaging for suspected diverticulitis, regardless of the value of leukocytes and of C-reactive protein (CRP).
What is the optimum pathway for imaging in elderly patients with suspected acute left colonic diverticulitis? CT or US or both?
Statement 2.1 The authors suggest the use of a CT-scan with IV-contrast in all elderly patients with suspected diverticulitis to confirm the diagnosis and to distinguish complicated from non-complicated diverticulitis.
Statement 2.2 In elderly patients with suspected diverticulitis who cannot undergo CT-scan with IV-contrast (i.e. severe acute or chronic kidney disease or contrast allergy), the authors suggest the use of US, MRI or CT-scan without IV-contrast as alternative diagnostic approaches, according to resources availability.
MANAGEMENT
What is the best treatment for uncomplicated diverticulitis (WSES stage 0) in elderly patients?
What is the best treatment for localized complicated diverticulitis without abscess (WSES stage 1a) diverticulitis in elderly patients?
Statement 3.1 The authors suggest that antibiotic therapy should be avoided in immunocompetent elderly patients with uncomplicated left colonic diverticulitis (WSES stage 0) without sepsis-related organ failures
Statement 4.1 The authors suggest antibiotic therapy administration for elderly patients with localized complicated left colonic diverticulitis with pericolic air bubbles or little pericolic fluid without abscess (WSES stage 1a).
What Is the best treatment for left colonic diverticulitis with abscess (WSES 1b-2a) in elderly patients?
Statement 5.1 In elderly stable patients with an abscess from acute left colonic diverticulitis (WSES stage 1b-2a) and without peritonitis, the authors suggest the administration of a broad-spectrum antibiotic therapy.
Statement 5.2 The authors suggest adding percutaneous drainage to antibiotic therapy in elderly patients with acute left colonic diverticulitis and an abscess larger than 4 cm (WSES stage 2a) when skills and facilities are available. Cultures from percutaneous drainage should be carried out to guide antibiotic therapy.
What is the best treatment for elderly patients with acute diverticulitis with distant free intraperitoneal air and without diffuse fluid (WSES stage 2b)?
Statement 6.1: In elderly patients with acute left colonic diverticulitis and CT findings of distant intraperitoneal free air and no free fluid (WSES stage 2b) the authors suggest against non-operative management as a viable option.
What is the best treatment for elderly patients with acute diverticulitis and diffuse peritonitis (WSES stage 3–4)?
Statement 7.1 In elderly patients with acute left colonic diverticulitis and diffuse peritonitis (WSES stage 3–4) the authors recommend against non-operative management as a viable option.
Statement 7.2 In elderly patients with acute left colonic diverticulitis and diffuse peritonitis (WSES stage 3–4) the authors recommend prompt and effective source control surgery.
When is a planned elective sigmoid resection indicated in elderly patients with left colonic diverticular disease?
Statement 8.1 The authors suggest against elective sigmoid resection after a conservatively treated episode of acute left colonic diverticulitis in asymptomatic elderly patients without stenosis, fistulae or recurrent diverticular bleeding.
Statement 8.2 The authors suggest considering elective sigmoid resection after a conservatively treated episode of acute left colonic diverticulitis in high-risk elderly patients, such as immunocompromised patients (if fit for surgery).
Statement 8.3 The authors suggest elective sigmoid resection in elderly patients (if fit for surgery) with left colonic diverticular disease complicated with stenosis, fistulae, or recurrent diverticular bleeding.
Statement 8.4 The authors suggest elective sigmoid resection in elderly patients (if fit for surgery) with very symptomatic left colonic diverticular disease, which compromises the quality of life.
Is endoscopic screening recommended for elderly patients treated with non-operative management for acute left colonic diverticulitis?
Statement 9.1 The authors suggest planning early colonic evaluation in elderly patients after an episode of acute left colonic diverticulitis.
SURGICAL TECHNIQUE
Should laparoscopic peritoneal lavage and drainage be considered in elderly patients with acute diverticulitis?
Statement 10.1 In elderly patients with acute left colonic diverticulitis and acute peritonitis the authors suggest against laparoscopic lavage as the preferred surgical approach due to the higher risk of failure to control the source of sepsis.
What is the best surgical procedure for elderly patients with perforated diverticulitis with generalized peritonitis: Hartmann resection or resection with primary anastomosis or damage control surgery?
Statement 11.1 The authors suggest that in elderly patients with perforated diverticulitis with generalized peritonitis, Hartmann operation and resection with primary anastomosis are both reasonable options.
Statement 11.2 The authors suggest that in elderly patients with perforated diverticulitis with generalized peritonitis and physiological derangement, Damage Control Surgery (emergency laparotomy, source control and application of open abdomen and abdominal vacuum-assisted closure) may be a viable option.
Should emergency laparoscopic sigmoidectomy (ELS) be considered in elderly patients with perforated diverticulitis with diffuse peritonitis?
Statement 12.1 The authors suggest that in stable elderly patients with perforated diverticulitis with diffuse peritonitis emergency laparoscopic sigmoidectomy can be performed by experienced laparoscopic surgeons.
ANTIBIOTIC THERAPY
What is the best anti-microbial regimen for elderly patients with localized complicated diverticulitis?
What is the best anti-microbial regimen for elderly patients with perforated diverticulitis with diffuse peritonitis?
Statement 13.1 In elderly patients with localized complicated diverticulitis the empirically designed anti-microbial regimen depends on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns.
Statement 14.1 In elderly patients with perforated diverticulitis with diffuse peritonitis the empirically designed anti-microbial regimen depends on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns.
When should discontinuation of anti-microbial treatment be considered?
Statement 15.1 In elderly patients with complicated diverticulitis a short course of antibiotic therapy (3–5 days) after adequate source control is a reasonable option.
Statement 15.2 In elderly patients with complicated diverticulitis who have ongoing signs of peritonitis or systemic illness (ongoing infection) beyond 5 to 7 days of antibiotic treatment, a further diagnostic investigation is indicated.
"After the publication of the WSES guidelines for the management of acute left-sided colonic diverticulitis in the emergency setting for the diagnosis and management of ALCD in the general population, the present guidelines represent, to the best of our knowledge, the first clinical guidelines for diagnosis and management of ALCD in elderly patients (> 65 years of age)," wrote the authors.
"Unfortunately, due to the lack of high-quality studies focusing on elderly patients and to the heterogeneity of the existing studies in the definition of an age cut-off for the characterization of an elderly patient, according to the GRADE methodology, all statements are based on low- or very low-quality evidence," they concluded.
Reference:
Fugazzola, P., Ceresoli, M., Coccolini, F. et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 17, 5 (2022). https://doi.org/10.1186/s13017-022-00408-0
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