The efficacy of nonoperative management of acute complicated diverticulitis

BACKGROUND: The surgical management of acute complicated diverticulitis has evolved to avoid emergency surgery in favor of elective resection. The optimal manner to accomplish this goal remains debatable. OBJECTIVE: The purpose of this study was to examine the efficacy of nonoperative management of acute diverticulitis with abscess or perforation. DESIGN: A retrospective review was performed of an institutional review board-approved database of patients admitted with a diagnosis of acute complicated diverticulitis from 1995 to 2008. Patient demographics, disease manifestation, management, and outcomes were collected. SETTINGS: This study was conducted at a tertiary care hospital/referral center. PATIENTS: Patients were included who presented with complicated diverticulitis defined as having an associated abscess or free air diagnosed by CT scan. MAIN OUTCOME MEASURES: Primary end points were the success of nonoperative management and need for surgery during the initial admission. RESULTS: One hundred thirty-six patients were identified with perforated diverticulitis: 19 had localized free air, 45 had abscess <4 cm or distant free air measuring <2 cm, 66 had abscess >4 cm or distant free air <2 cm, and 6 had distant free air with free fluid. Thirty-eight patients (28%) required percutaneous abscess drains and 37 (27%) required parenteral nutrition. Only 5 patients (3.7%) required urgent surgery at the time of admission, and 7 (5%) required urgent surgery for failed nonoperative management. Thus, the overall success rate of nonoperative management was 91%. One hundred twenty-four of 131 (95%) patients were treated with nonoperative management successfully. Twenty-five of 27 (92.5%) patients with free air remote from the perforation site were successfully treated nonoperatively. CONCLUSIONS: Nonoperative management of acute complicated diverticulitis is highly effective. For patients with free air remote from the site of perforation, nonoperative management is able to convert an emergent situation into an elective one in 93% of cases. The decision to attempt nonoperative therapy must be made based on the patient's physiologic state and associated comorbidities.