Accepted Manuscript
Changing paradigms in the management of diverticulitis
Nir Horesh, MD, Nir Wasserberg, MD, Andrew P. Zbar, MD FACS, Aviad Gravetz,
MD, Yaniv Berger, MD, Mordechai Gutman, MD FACS, Danny Rosin, MD, Oded
Zmora, MD
PII:
S1743-9191(16)30281-3
DOI:
10.1016/j.ijsu.2016.07.072
Reference:
IJSU 2961
To appear in:
International Journal of Surgery
Received Date: 3 June 2016
Revised Date:
21 July 2016
Accepted Date: 26 July 2016
Please cite this article as: Horesh N, Wasserberg N, Zbar AP, Gravetz A, Berger Y, Gutman M, Rosin
D, Zmora O, Changing paradigms in the management of diverticulitis, International Journal of Surgery
(2016), doi: 10.1016/j.ijsu.2016.07.072.
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Changing paradigms in the management of diverticulitis
Nir Horesh¹, MD; Nir Wasserberg², MD; Andrew P. Zbar¹, MD FACS; Aviad
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Gravetz¹, MD; Yaniv Berger¹, MD; Mordechai Gutman¹, MD FACS, Danny Rosin¹
MD, Oded Zmora¹, MD
1. Department of Surgery and Transplantation, Chaim Sheba Medical Center
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Ramat Gan Israel (affiliated to the Faculty of Medicine, Tel Aviv University)
2. Department of Surgery B, Rabin Medical Center, Petach Tikva 49100;
affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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69978, Israel
Corresponding author: Nir Horesh, M.D., Department of Surgery and
Transplantations B, Sheba Medical Center, Tel-Hashomer, 52621, Israel; Tel: +972-
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507-316266; Fax: +972-3-5302316; E-mail: nir_horesh@hotmail.com
Keywords – Diverticulitis, Emergency Surgery, Elective Surgery
Abstract Word Count – 118
Article Word Count - 1869
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Keywords – Diverticulitis, Emergency Surgery, Elective Surgery
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Abstract
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Changing paradigms in the management of diverticulitis
The management of diverticular disease has evolved in the last few decades from a
structured therapeutic approach including operative management in almost all cases to a
variety of medical and surgical approaches leading to a more individualized strategy.
There is an ongoing debate among surgeons about the surgical management of
diverticular disease, questioning not only the surgical procedure of choice, but also about
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who should be operated and the timing of surgery, both in complicated and
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uncomplicated diverticular disease. This article reviews the current treatment of
diverticulitis, with a focus on the indications and methods of surgery in both the
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emergency and elective settings. Further investigation with good clinical data is needed
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for the establishment of clear guidelines.
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Introduction
Diverticular disease is relatively common in the western world. Already in 1975,
the estimated prevalence in the United States was about 60% in the over-65-year age
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group[1]. This rate has been steadily increasing concomitant with the increasing life
expectancy of the general population. Accordingly, hospitals have witnessed a growing
number of admissions for acute diverticular disease. In 1988, diverticulitis and its
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complications accounted for 2.2 million hospitalizations in the United States, incurring
cumulative health care costs of $2.5 billion[2]. Between 1988 and 2005, this figure rose
by 26%[3]. These findings were echoed in studies from Europe, where acute diverticulitis
accounts for more than 200,000 annual hospital admissions and poses a health burden
exceeding €300 million[4].
The reported trends have prompted an ongoing search for novel, efficient and
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cost-effective therapeutic strategies, and in the last 20 years, advances and innovations in
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imaging and surgical techniques have yielded significant changes in the management of
diverticular disease. The paradigm has shifted from widely accepted stringent guidelines
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outlining specific indications for antibiotic administration, hospital admission, emergency
surgery (including the procedure of choice), and elective surgery to a wide range of
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available options at all stages of the disease. The current possibility of tailoring treatment
to the individual patient has made sound surgical judgment and surgical experience of
prime importance in this setting, and it is widely acceptable to choose the therapeutic
intervention based on the specific patient, in order to lower the risks of morbidities and
complications and improving patient quality of life.
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The aim of the present study was to review the important changes in the
management of diverticulitis, with an emphasis on the indications for surgery in the
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emergency and elective settings.
Diagnosis
Clinical manifestations in acute diverticular disease vary, and depend mainly on
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the severity of the inflammatory process of the disease and the presence or absence of
complications. The most common symptom is left lower quadrant pain, occurring in
70% of cases, lasting for more than 24 hours in most cases [5]. Other manifestations
include vomiting and nausea, changes in bowel movement and urinary symptoms may
also be part of the clinical presentation. Physical findings comprise of left lower
abdominal tenderness in most cases, abdominal distension and a palpable mass are also
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common, mainly in acute diverticulitis complicated by an abscess formation [6]. Low
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grade fever with mild leukocytosis is common [7], but studies have showed that almost
half of all patients with acute diverticulitis have normal WBC levels [8].
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Although the main clinical manifestation of diverticulitis is lower left abdominal
pain, it has a wide differential diagnosis. This is often a misleading symptom that can
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result in misdiagnosis in 34% to 68% of patients[9-11]. Also, caregivers today must
acknowledge that though left sided diverticulitis is much more common in western
populations, in many Asian countries and eastern populations the predominant
presentation of acute diverticulitis is seen on the right side of the colon [12-14].
Therefore, in suspected cases, clinicians usually base the diagnosis on imaging studies,
particularly computed tomography (CT) which has been found to have high sensitivity
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and specificity for acute diverticulitis[15, 16]. The role of colonoscopy in diagnosis is
mainly to confirm the presence of diverticuli as seen on computed tomography, mainly to
exclude malignant findings, a task often difficult for the radiological studies. However,
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the need for endoscopic evaluation following an attack of acute diverticulitis is
controversial, as some studies [17, 18], including one performed in our institute
demonstrated no clear advantage for colonoscopy following an episode of acute
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diverticulitis [19].
Staging
Staging is used in various diseases to score severity and aid clinicians in treatment
decisions. Hinchey et al. [20] developed the first staging system for perforated
diverticulitis in 1978. The classification relates to infectious and inflammatory spread
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following colonic perforation, escalating from a small pericolic abscess (Grade 1) up to
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fecal peritonitis (Grade 4). It is still commonly used by physicians and aids with
therapeutic decisions. Almost 20 years after Hinchey first described his classification,
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Sher et al [21] modified the Hinchey score to account for the increasing use of CT as a
diagnostic modality, and it subsequently became the most common staging method
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applied by surgeons for acute diverticulitis worldwide. Several alternative systems have
been introduced as well in the interim, such as the Köhler classification, which is based
on symptom severity and presentation[22], and the classification of Ambrosetti et al. [23],
which uses CT findings as the reference for selecting treatment.
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Treatment
Uncomplicated diverticulitis
Mild or moderate diverticulitis is usually treated conservatively. Traditionally,
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most patients are hospitalized to receive intravenous antibiotics against aerobic and
anaerobic microbial agents and fluids along with mandatory bowel rest. However, several
recent studies have shown that in the absence of significant comorbidities, outpatient
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management with oral antibiotics is equally safe and effective [24-30]. In a randomized trial
of outpatient management of uncomplicated diverticulitis, Biondo et al [31] reported
excellent results and reduced health care-costs. These findings were supported by a
systematic review wherein outpatient management led to a decrease of more than 80% in
health-care costs in some cases with no loss of effectiveness [32]. Nevertheless, the inhospital administration of intravenous antibiotics, usually a combination of anti-aerobic
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and anaerobic bacteria such as Fluoroquinolone and Metronidazole [33] or Amoxicillin-
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clavulanate [34] is still warranted in patients with comorbidities or a more severe clinical
and radiologic presentation[35]. The latter is also true for right sided diverticulitis, which
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according to several studies in recent years usually responds to a non-operative treatment,
with a low recurrence rate after the first attack [36, 37].
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There is also evidence suggesting that uncomplicated diverticulitis may be
treatable without antibiotics at all [38-40]. Chabok et al [38] conducted a multicenter trial in
which patients were randomized to receive hospital treatment with or without antibiotics.
They found no between-group differences in complication rate, length of hospital stay, or
recurrence.
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Complicated acute diverticulitis
Emergency surgery
About 15% to 25% of cases of acute diverticulitis are associated with
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complications that require surgery. Until recently, peridiverticular abscess was the main
indication for surgery, but thanks to improvements in imaging and drainage techniques, it
is now usually manageable by percutaneous drainage and intravenous antibiotics[41].
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Today, the main indication for surgery is colonic perforation, which can lead to
acute peritonitis and subsequent significant morbidity and occasional mortality. Up to the
early 1980s colonic perforation was treated by a standard three-stage procedure that
included a diverting proximal colostomy and drainage of the perforation site in the acute
setting to alleviate sepsis, followed by resection of the involved colonic segment in an
elective setting, and later, colostomy closure[42]. Despite the considerable intervals
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between the steps to allow for recovery, mortality rates were high[43]. Thereafter,
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perioperative care improved, leading to the introduction of the two-stage Hartmann
procedure [44, 45]: primary resection of the perforated segment and end-colostomy
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followed by colostomy closure [46, 47]. The Hartmann procedure was associated with better
outcome and fewer complications than other surgical techniques, although there was no
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decrease in mortality rates[48]. In 2000, the American Society of Colon and Rectal
Surgeons recommended the Hartmann procedure as the gold standard for the treatment
for acute perforated diverticular disease with peritonitis[49].
Another viable option is resection of the diseased segment with primary
anastomosis and diverting loop ileostomy. This approach has been associated with a
favorable outcome in selected low-risk, hemodynamically stable patients, but there are as
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yet no large-scale randomized controlled trials. Oberkofler et al.[50] compared patients
with Hinchey class III-IV perforation who were randomized to undergo primary resection
with anastomosis or the Hartmann procedure. They found that the primary anastomosis
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group was characterized by a lower rate of stoma reversal fewer serious complications,
less operating time, shorter hospital stay, and lower health care costs, although the overall
complication and mortality rates were similar to the Hartmann procedure group.
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Several studies have suggested the incorporation of laparoscopic techniques
during surgery for colonic perforation due to acute diverticulitis. Studies of the benefits
of peritoneal laparoscopic lavage and drainage in these cases reported excellent outcomes
with less risk compared with the Hartmann procedure[51-57], especially in stable patients
with less severe peritonitis (Hinchey class III)[58, 59]. However, reviews and meta-analyses
that included all these studies pointed to the importance of good patient selection and the
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need for further investigation to confirm the place of laparoscopic peritoneal lavage and
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drainage in this setting [51, 56, 60, 61]. A small retrospective case series in our department
recently showed that laparoscopic peritoneal lavage and drainage resolved the acute
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symptoms in all patients, but 30% required additional surgery (91). In 2015, Vennix etl al
[62] published the results of the LOLA arm, part of the LADIES Trial [63], comparing
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two randomized patient groups, treated with laparoscopic lavage and drainage or
resection with primary anastomosis, concluding that laparoscopic lavage has no
advantage over resection and primary anastomosis. Furthermore, the results of another
randomized controlled study, the SCANDIV trial [64], comparing two groups treated
surgically with laparoscopic lavage or colonic resection, demonstrated that laparoscopic
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lavage had more post-operative complications and required a higher rate of additional
surgical intervention.
At present, for complicated diverticulitis in unstable patients with fecal peritonitis,
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Hartmann’s procedure continues to be the surgical method of choice [65-67].
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Elective Surgery
Elective surgery has played an important role in the definitive treatment of acute
diverticulitis, although the indications have changed dramatically in recent years.
Traditionally, elective surgery was recommended after a second episode of acute
diverticulitis and for young patients after a solitary attack in order to prevent complicated
diverticulitis and the possible need for riskier emergency surgery with a temporary
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colostomy. Approximately one-third of patients with acute diverticulitis meet these
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criteria [22, 68, 69]. However, several sentinel studies have raised concerns about these
guidelines. The systematic review of Janes et al [70] failed to find evidence supporting the
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recommendation for surgery after two attacks of acute diverticulitis, and the decisionanalysis study of Salem et al [71] showed that patients operated after four episodes of acute
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diverticulitis had lower mortality rates, fewer colostomies, and lower health-care costs
than patients operated after two episodes. Accordingly, most surgeons today determine
the need for surgery on a case-by-case basis, depending on certain variables[72]. The most
recent guidelines for the surgical management of diverticulitis, published in 2014[73],
recommend that elective surgery be performed in the presence of ongoing complications
of acute diverticulitis, such as colocutaneous, colovesicle, or colovaginal fistulas, or after
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recurrent uncomplicated episodes of acute diverticulitis that adversely impact the
patient’s quality of life. Thus, the chances that every recurrent episode will be followed
by emergency surgery with temporary colostomy are low and probably within the range
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of the risk of complications of elective surgery itself [74-76]. Nevertheless, the occurrence
of a series of recurrent symptomatic attacks probably warrants surgical treatment.
The need for elective surgical resection following conservatively treated
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complicated diverticulitis has also been challenged. As noted, the improvements in
invasive radiology and broad-spectrum antibiotics have considerably raised the likelihood
of complete resolution of peridiverticular abscess and local perforation with nonoperative treatment alone[76], thereby lowering the likelihood of a recurrent attack
warranting emergency surgery. This is probably also true for episodes of perforated
diverticulitis requiring lavage and drainage, which has been associated with a low
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recurrence rate [77-79]. Other factors contributing to the decision to use a more aggressive
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therapeutic approach include patient age and underlying comorbidities [78, 80]. Several
studies recommend elective surgery in immune-compromised patients [81, 82], but a recent
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publication by Biondo et al [83] demonstrated that it is unnecessary if medical treatment
was successful. Further randomized trials are needed to determine the definitive
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guidelines for surgical treatment of acute diverticulitis.
The number of elective resections for diverticulitis performed laparoscopically
has been increasing since the late 1990s. Laparoscopic surgery in the treatment of acute
diverticulitis has been associated with several benefits [80, 84-90]. Klarenbeek et al. [91]
prospectively compared laparoscopic and open sigmoid resection for acute diverticulitis
and found that laparoscopic surgery was associated with shorter hospital stay, fewer
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complications, and attenuated pain. A meta-analyses including more than 2800 patients
published by Sidiqqui et al [92] in 2010, compared laparoscopic surgery and open surgery
for diverticular surgery. Laparoscopy was superior in surgical outcome including
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decreased rates of surgical of surgical wound infection, blood transfusions and paralytic
ileus. a systemic review by Gaertner et al showed that laparoscopy had reduced
morbidity, shorter hospital stay and lower costs [93] when compared with open surgery. In
a fairly low complication rate of 7.6%.
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a recent prospective trial, Schwandner et al. [94] reported a conversion rate of 6.8%, with
To summarize, we believe that the treatment for acute diverticulitis should be
tailored to the clinical status of the patient. Outpatient management should be considered
in selected patients with uncomplicated diverticulitis, mainly mildly ill and younger
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patients without significant comorbidities. Hospitalization should be considered in all
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patients with complicated diverticular disease and patients with uncomplicated
diverticulitis but without clinical response to oral treatment, requiring intravenous
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antibiotics and close up medical follow up.
Surgical treatment should also be considered on a patient to patient basis. In the
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emergency setting, the clinical status of the patient and the radiological classification
should play a role when deciding on the surgical strategy. Though the Hartmann's
procedure is still the most common procedure for colonic diverticular perforation, there is
enough evidence that most patients with a pelvic or an intra-abdominal abscess could be
managed without surgery. These patients might be in need of a percutaneous drainage in
large abscesses or if they don't improve clinically with antibiotics alone. Emergency
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surgery should be considered in all patients with a Hinchey class 3 complicated
diverticulitis in order to achieve septic source control. The decision for a laparoscopic vs.
open surgery should depend on the surgical capabilities of the surgeon and on the clinical
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status of the patient. Younger patients with less comorbidities could be good candidates
for laparoscopic surgery including peritoneal lavage and drainage in Hinchey Class III
perforations or for a resection with primary anastomosis in capable hands. We
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recommend that all patients with fecal peritonitis should undergo bowel resection with
proximal diversion.
In the elective setting, surgery should be offered to patients with recurrent attacks
and that the disease has a significant impact on their quality of life, including multiple
hospital admissions or constant abdominal pain. Elective surgery should also be offered
to patients presenting with complications including fistula and bowel strictures.
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Immunocompromised patients are also prone for diverticular disease complications and
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therefore should also be considered for surgery. Finally, the decision should be based on
the patients' clinical status after a joint discussion about the possible outcomes of the
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surgical intervention.
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Conclusion
The management of diverticular disease has changed notably in recent years and
is still evolving, thanks to advances in diagnostic and nonoperative interventional
capabilities. Surgical treatment can now be avoided in many cases that would have
routinely been approached surgically in the past. The availability of laparoscopic
techniques has also changed the treatment paradigm for patients with recurrent episodes
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of acute diverticulitis to a more individualized approach focusing mainly on quality of
life. Even the need for antibiotics for uncomplicated diverticulitis has recently been
challenged. In emergency settings the Hartmann procedure, though still widely used, has
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been replaced in certain cases with drainage and peritoneal lavage though recent data
suggest it carries a certain risk when compared with colonic resection. These treatment
strategies should be validated in large series and introduced to surgeons worldwide in
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order to update guidelines with the most current therapeutic options.
Conflict of interest –
None of the authors has a conflict of interest to declare.
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Highlights
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• This review outlines the most significant changes that diverticular
disease management has seen in recent years
• The review gives physicians an updated view on the most current
studies of outpatient and inpatient treatment for acute
diverticulitis
• The review focus on the surgical management and the indications
for surgery, both in the emergency and the elective setting