Management of acute colonic diverticulitis: 2020 updated WSES guidelines

The World Society of Emergency Surgery (WSES) has released its updated guidelines for the management of ALCD which have been published in the World Journal of Emergency Surgery. It is an update on guidelines published in 2016.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for the management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD.

Key recommendations include-

What is the best way to make a diagnosis of ALCD?

In patients with suspected ALCD, we suggest a complete assessment of the patients using clinical history, signs, laboratory inflammation markers, and radiological findings (weak recommendation based on very low-quality evidence, 2D).

In patients with suspected, ALCD we suggest against diagnosis based only on clinical examination (weak recommendation based on very low-quality evidence, 2D).

What is the best imaging technique in patients with suspected ALCD? What is the role of ultrasound (US) in patients with ALCD?

In patients with suspected ALCD, we suggest a contrast-enhanced CT scan of the abdomen as the imaging technique of the first choice (weak recommendation based on moderate-quality evidence, 2B).

We suggest to use US in the initial evaluation of patients with suspected ALCD where it is performed by an expert operator. It has wide availability and easy accessibility. A step-up approach with CT performed after an inconclusive or the negative US may be a safe approach for patients suspected of acute diverticulitis (weak recommendation based on moderate-quality evidence, 2B).

Are immunocompromised patients with ALCD at risk for failure of standard, non-operative treatment?

We suggest that immunocompromised patients with ALCD be considered at high risk for failure of standard, non-operative treatment (weak recommendation based on very low-quality evidence, 2D).

Should antibiotics be recommended in immunocompetent patients with uncomplicated acute diverticulitis?

In immunocompetent patients with uncomplicated diverticulitis without signs of systemic inflammation, we recommend to not prescribe antibiotic therapy (strong recommendation based on high-quality evidence, 1A).

In patients requiring antibiotic therapy, we recommend oral administration whenever possible, primarily, because an early switch from intravenous to oral therapy may facilitate a shorter inpatient length of stay (strong recommendation based on moderate-quality evidence, 1B).

Could patients with uncomplicated ALCD be treated as an outpatient?

We suggest management in an outpatient setting for patients with uncomplicated ALCD and no comorbidities. We suggest re-evaluation within 7 days. If the clinical condition deteriorates, a re-evaluation should be carried out earlier (weak recommendation based on moderate-quality evidence, 2B).

What is the best treatment for patients with acute diverticulitis with CT findings of pericolic gas?

In patients with CT findings of pericolic extraluminal gas, we suggest a trial of non-operative treatment with antibiotic therapy (weak recommendation based on low-quality evidence, 2C).

What is the best treatment for patients with a small diverticular abscess (< 4–5 cm)? What is the best treatment for patients with a large diverticular abscess?

For patients with a small (< 4–5 cm) diverticular abscess, we suggest an initial trial of non-operative treatment with antibiotics alone (weak recommendation based on low-quality evidence, 2C).

We suggest treating patients with large abscesses with percutaneous drainage combined with antibiotic treatment; whenever percutaneous drainage of the abscess is not feasible or not available, we suggest to initially treat patients with large abscesses with antibiotic therapy alone, clinical conditions permitting. Alternatively, operative intervention is required (weak recommendation based on low-quality evidence, 2C).

Should an early colonic evaluation be planned in patients treated non-operatively for a diverticular abscess? Should an early colonic evaluation be recommended for patients with a CT-proved uncomplicated acute diverticulitis treated non-operatively?

In patients with diverticular abscesses treated non-operatively, we suggest to plan an early colonic evaluation (4–6 weeks) (weak recommendation based on low-quality evidence, 2C).

In patients with CT-proven uncomplicated diverticulitis treated non-operatively, we do not recommend routine colonic evaluation (weak recommendation based on moderate-quality evidence, 2B).

What is the role of non-operative treatment in patients with CT findings of distant gas without diffuse intra-abdominal fluid?

In patients with CT findings of distant free gas without diffuse intra-abdominal fluid, we suggest a non-operative treatment in selected patients only if a close follow-up can be performed (weak recommendation based on very low-quality evidence, 2D).

Should laparoscopic lavage and drainage be recommended in patients with diffuse peritonitis due to diverticular perforation?

We suggest performing laparoscopic peritoneal lavage and drainage only in very selected patients with generalized peritonitis. It is not considered as the first-line treatment in patients with peritonitis from acute colonic diverticulitis (weak recommendation based on high-quality evidence, 2A).

Should primary anastomosis with or without protecting stoma be preferred instead of Hartmann's procedure in patients with diffuse peritonitis from diverticular perforation?

We recommend Hartmann's procedure (HP) for managing diffuse peritonitis in critically ill patients and in selected patients with multiple comorbidities (strong recommendation based on low-quality evidence, 2B).

In clinically stable patients with no comorbidities, we suggest primary resection with anastomosis with or without a diverting stoma (weak recommendation based on low-quality evidence, 2B).

Should laparoscopic resection be preferred to open resection in patients with diffuse peritonitis due to perforated diverticulitis?

In patients with diffuse peritonitis due to perforated diverticulitis, we suggest performing an emergency laparoscopic sigmoidectomy only if technical skills and equipment are available (weak recommendation based on low-quality evidence, 2C).

Should damage control surgery with staged laparotomies be recommended in patients with acute peritonitis due to diverticular perforation?

We suggest damage control surgery (DCS) with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforation (weak recommendation based on low-quality evidence, 2C).

What factors should be considered in planning elective resection in cases of acute diverticulitis treated non-operatively?

We suggest evaluating patient-related factors and not a number of previous episodes of diverticulitis in planning elective sigmoid resection (weak recommendation based on very low-quality evidence, 2D).

After an episode of ALCD treated conservatively, we suggest planning of an elective sigmoid resection in high-risk patients, such as immunocompromised patients (weak recommendation based on very low-quality evidence, 2D).

What is the optimal antibiotic therapy for patients with diffuse peritonitis due to diverticular perforation? What is the optimal duration of antibiotic therapy after surgical source control in diffuse peritonitis due to diverticular perforation?

We suggest choosing the empirically designed antibiotic regimen on the basis of the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns (strong recommendation based on moderate-quality evidence, 1B).

We suggest a 4-day period of postoperative antibiotic therapy in complicated ALCD if source control has been adequate (weak recommendation based on moderate-quality evidence, 2B).

Which are the principles of the treatment of acute right-sided colonic diverticulitis?

Although studies have shown that the percentage of complications requiring surgery is higher in patients with ALCD than in patients with ARCD, the principles of diagnosis and treatment of patients with ARCD are similar to those with ALCD. We suggest that all the statements for ALCD also apply to ARCD.

The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

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