Treatment protocol of acute complicated diverticulitis

Aim To review the literature concerning acute complicated diverticulitis treatment and on the basis of the data analysis to suggest the acute complicated diverticulitis treatment protocol. Methods Using PubMed, Medline, Embase, Cochrane, Medscape electronic databases the literature published in the period 2008–2013, on acute diverticulitis treatment is reviewed. The search was made using the keywords (diverticulitis, perforation, peritonitis, Hartmann’s operation, primary anastomosis, laparoscopic lavage, Hinchey). Only the articles that present data on the basis of randomized comparative studies were analysed. Inclusion criteria had been set before starting the literature review – the study cohort of at least 100 patients with acute diverticulitis, the diagnosis confirmed by computer tomography using the Hinchey classification, the results and conclusions being statistically significant. Results Eleven articles were analysed. For Hinchey I–II acute diverticulitis patients, conservative or minimally invasive treatment is indicated – antibiotic therapy or percutaneous abscess drainage of abscesses larger than 5 cm. For Hinchey III–IV patients surgical treatment is indicated. No statistically significant differences were found when comparing colorectal resection and drainage with suturing of the perforations. Comparing colon resection with primary anastomosis (PA) and Hartmann type (HP) operation, statistically significant differences were found: mortality 9.7% in PA and 21.95% in HP; surgical reinterventions 6.6% in PA and 5.3% in HP; hospitalization duration 8.65 days in PA and 15.08 days in the HP group. Comparing the PA group with laparoscopic abdominal cavity lavage (LLD), no statistically significant differences were found. There were no deaths in either of the groups, hospital stay after LLD was 8 days and after PA 17 days. After LLD operations, for 71.43% of the patients delayed laparoscopic resection (LR) was performed, but the total duration of hospitalization after LLD and LR was less than the hospitalization duration after PA. Conclusions In Hinchey I–II complicated acute diverticulitis, conservative treatment with broad spectrum antibiotics or by minimally invasive methods (percutaneous abscess drainage under UG or CT control) is recommended. In Hinchey III–IV diverticulitis, surgical treatment is indicated (PA, HP). Methods of treatment for each Hinchey class are proposed (refer to the scheme). Randomized controlled trials are needed to compare and evaluate various acute complicated diverticulitis treatment methods