Strategies in Perforated Diverticulitis

Although diverticulitis is a common disease affecting the gastrointestinal tract, few is known about the optimal surgical treatment of its most severe form: perforated diverticulitis. Regardless of the selected operation, perforated diverticulitis is associated with mortality rates up to 30%. Mortality is related to age and comorbidity of the patient, severity of disease and the availability of a specialist colorectal surgeon. Today, the most frequently performed operation remains Hartmann’s procedure, which leaves the patient with an end colostomy. Specialist colorectal surgeons are more likely to perform resection with primary anastomosis, with comparable outcome as Hartmann’s procedure. Recently a new surgical treatment strategy has been introduced in which resection of the affected bowel segment is prevented: laparoscopic lavage and drainage of the abdomen. A national wide randomized controlled study has started in 2010 to compare the three different treatment strategies in perforated diverticulitis with generalized peritonitis. Besides a high mortality rate on short-term, patients after perforated diverticulitis have a poor long-term survival compared to the general Dutch population. This is mainly caused by the general condition of this category of patients. They also have an impaired quality of life compared to the general population, mainly caused by the attendance of their end colostomy. When this stoma is prevented (primary anastomosis) or reversed, quality of life returned to normal. Reversal of Hartmann’s procedure is a technical difficult operation, associated with complications and even mortality. A new minimal invasive surgical technique has been developed, that showed favorable results compared to the standard.