Acute Complicated Diverticulitis - Surgical Management (WSES 2020)

Algorithm Steps

1. ▶

   Start

   Acute Left-Sided Colonic Diverticulitis

   LLQ pain, fever, leukocytosis. CT confirms diverticulitis. Now assess for complications requiring surgical consideration.

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      Action

      CT Staging - Modified Hinchey Classification

      Stage 0: Uncomplicated - thickened wall, pericolic fat stranding. Stage Ia: Confined pericolic inflammation ± phlegmon. Stage Ib: Pericolic or mesocolic abscess. Stage II: Pelvic, distant intra-abdominal, or retroperitoneal abscess. Stage III: Purulent peritonitis (no visible perforation). Stage IV: Feculent peritonitis (visible perforation, fecal material).

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         Decision

         Stage Classification?

         Determines management pathway: Stage 0-Ia: Medical. Stage Ib-II: Abscess management. Stage III-IV: Surgical emergency.

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            Action

            Stage 0-Ia: Uncomplicated

            Medical management: 1) Outpatient if low-risk (minimal tenderness, tolerating PO, no comorbidities). 2) Antibiotics 7-10 days (can omit for very mild cases per recent evidence). 3) Clear liquid → advance diet. 4) Follow-up in 2-4 weeks. 5) Colonoscopy 6-8 weeks after resolution.

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               Outcome

               Recovery

               Source controlled. Continue recovery. Plan stoma reversal if applicable (3-6 months). Long-term: High-fiber diet, colonoscopy surveillance.

            2. ⚠

               Warning

               ⚠️ High-Risk Populations

               Immunocompromised patients (steroids, chemotherapy, transplant) have: Higher perforation rates, atypical presentations, higher mortality. Lower threshold for surgery. Primary anastomosis generally avoided.

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            Action

            Stage Ib-II: Abscess Present

            Abscess identified on CT. Size determines approach.

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               Decision

               Abscess Size?

               <3cm: Usually resolves with antibiotics alone. 3-5cm: Consider percutaneous drainage. >5cm: Percutaneous drainage recommended.

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                  Action

                  Small Abscess (<3-4cm)

                  IV antibiotics. NPO or clear liquids. Close monitoring - serial exams, repeat CT if worsening. Most resolve with antibiotics alone. If no improvement in 48-72h, reassess for drainage.

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                     Action

                     Postoperative Care

                     IV antibiotics (5-7 days total). Diet advancement as tolerated. Stoma education if applicable. DVT prophylaxis. Monitor for complications: Leak, abscess, ileus, wound infection. Plan: Colonoscopy to rule out malignancy after recovery.

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                  Action

                  Large Abscess (>3-4cm): Drain

                  CT-guided percutaneous drainage. Continue IV antibiotics. Leave drain until output minimal and patient improving. Success rate ~80%. Failure → surgery. After resolution: Plan elective sigmoid resection (controversial - may observe if first episode).

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            Action

            Stage III-IV: Peritonitis

            Generalized peritonitis = surgical emergency. Distinguish: Stage III (purulent) vs Stage IV (feculent). Both require OR but approach may differ.

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               Decision

               Patient Hemodynamically Stable?

               Assess: MAP >65, responding to fluids, no vasopressors, mentating, lactate trending down. Stability affects operative options.

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                  Decision

                  Stable Patient: Surgical Options

                  Consider: Contamination severity, patient factors, surgeon expertise, potential for primary anastomosis.

                  1. ●

                     Action

                     Hartmann's Procedure

                     Sigmoid resection, end colostomy, rectal stump closure. Traditional standard. Best for: Unstable patients, severe contamination, poor tissue quality, immunocompromised, uncertain viability, limited expertise for anastomosis. Reversal rate: 40-60% (often permanent).

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                     Action

                     Resection + Primary Anastomosis ± Ileostomy

                     Sigmoid resection with colorectal anastomosis. Consider protecting loop ileostomy. Candidates: Stable patient, Hinchey III (not IV), good tissue quality, experienced surgeon. Benefits: No permanent stoma, single hospitalization for reversal. May be comparable outcomes to Hartmann's in selected patients.

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                     Action

                     Laparoscopic Lavage (Controversial)

                     FOR: Hinchey III (purulent) only. NOT for: Hinchey IV, visible perforation, fecal contamination. Procedure: Laparoscopic washout (6L+ saline), drain placement, NO resection. Role uncertain - higher failure rate vs resection in trials (SCANDIV, LADIES). May be option in selected cases with experienced surgeon.

               2. ●

                  Action

                  Unstable: Damage Control

                  Hemodynamically unstable = abbreviated surgery. Resect perforated segment, washout, end colostomy (Hartmann's), leave abdomen open if ACS risk. ICU resuscitation. No primary anastomosis in unstable patient.