Skip to main content
SpringerLink
Log in

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

  • Review
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Background

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

Method

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan–guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30–90 days of index admission. Data were stratified by three arbitrary time intervals: 1986–2000, 2000–2010, and after 2010. The primary outcome was calculated for those groups and compared.

Results

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000–2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

Conclusion

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

Data Availability

Data used in this study are previously published data.

References

  1. Slack WW (1962) The anatomy, pathology, and some clinical features of divericulitis of the colon. Br J Surg 50:185–190

    Article  CAS  PubMed  Google Scholar 

  2. Hughes LE (1969) Postmortem survey of diverticular disease of the colon. II. The muscular abnormality of the sigmoid colon. Gut. 10(5):344–351

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Hobson KG, Roberts PL (2004) Etiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 17(3):147–153

    Article  PubMed  PubMed Central  Google Scholar 

  4. Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology. 2019 Jan 17. [Ahead of print]. pii: S0016-5085(19)30046-0. doi:https://doi.org/10.1053/j.gastro.2018.12.033.

  5. Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109

    CAS  PubMed  Google Scholar 

  6. Kaiser AM, Jiang J-K, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW (2005) The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 100(4):910–917

    Article  PubMed  Google Scholar 

  7. Galetin T, Galetin A, Vestweber K-H, Rink AD (2018) Systematic review and comparison of national and international guidelines on diverticular disease. Int J Color Dis 33(3):261–272

    Article  CAS  Google Scholar 

  8. Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, Consten EC, van der Hoeven J, Eijsbouts QA, Faneyte IF, Bemelman WA, Dijkgraaf MG, Boermeester MA, Dutch Diverticular Disease (3D) Collaborative Study Group (2017) Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 104(1):52–61

    Article  CAS  PubMed  Google Scholar 

  9. Van De Wall BJM, Stam MAW, Draaisma WA et al (2017) Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2(1):13–22

    Article  PubMed  Google Scholar 

  10. Schultz JK, Wallon C, Blecic L, Forsmo HM, Folkesson J, Buchwald P, Kørner H, Dahl FA, Øresland T, Yaqub S, SCANDIV Study Group (2017) One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis. Br J Surg 104(10):1382–1392

    Article  CAS  PubMed  Google Scholar 

  11. Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, Schwarz L, Mege D, Sielezneff I, Sabbagh C, Tuech JJ (2017) Hartmann’s procedure or primary anastomosis for generalized peritonitis due to perforated diverticulitis: a prospective multicenter randomized trial (DIVERTI). J Am Coll Surg 225(6):798–805

    Article  PubMed  Google Scholar 

  12. Mueller PR, Saini S, Wittenburg J, Simeone J, Hahn PF, Steiner E, Dawson SL, Butch RJ, Stark DD, Ottinger LW (1987) Sigmoid diverticular abscesses: percutaneous drainage as an adjunct to surgical resection in 24 cases. Radiology. 164(2):321–325

    Article  CAS  PubMed  Google Scholar 

  13. Stabile BE, Puccio E, van Sonnenberg E, Neff CC (1990) Preoperative percutaneous drainage of diverticular abscesses. Am J Surg 159(1):99–104

    Article  CAS  PubMed  Google Scholar 

  14. Bernini A, Spencer MP, Wong WD, Rothenberger DA, Madoff RD (1997) Computed tomography-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome. Dis Colon Rectum 40(9):1009–1013

    Article  CAS  PubMed  Google Scholar 

  15. Singh B, May K, Coltart I, Moore NR, Cunningham C (2008) The long-term results of percutaneous drainage of diverticular abscess. Ann R Coll Surg Engl 90(4):297–301

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Gaertner WB, Willis DJ, Madoff RD, Rothenberger DA, Kwaan MR, Belzer GE, Melton GB (2013) Percutaneous drainage of colonic diverticular abscess. Dis Colon Rectum 56(5):622–626

    Article  PubMed  Google Scholar 

  17. Lamb MN, Kaiser AM (2014) Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis Colon Rectum 57(12):1430–1440

    Article  PubMed  Google Scholar 

  18. Elagili F, Stocchi L, Ozuner G, Mody R, Baker ME, Kiran RP (2015) Predictors of postoperative outcomes for patients with diverticular abscess initially treated with percutaneous drainage. Am J Surg 209(4):703–708

    Article  PubMed  Google Scholar 

  19. Gregersen R, Mortensen LQ, Burcharth J, Pommergaard H-C, Rosenberg J (2016) Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 35:201–208

    Article  PubMed  Google Scholar 

  20. Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM (2016) Medically treated diverticular abscess associated with high risk of recurrence and disease complications. Dis Colon Rectum 59(3):208–215

    Article  PubMed  Google Scholar 

  21. Jalouta T, Jrebi N, Luchtefeld M, Ogilvie JW (2017) Diverticulitis recurrence after percutaneous abscess drainage. Int J Color Dis 32(10):1367–1373

    Article  Google Scholar 

  22. Buchwald P, Dixon L, Wakeman CJ, Eglinton TW, Frizelle FA (2017) Hinchey I and II diverticular abscesses: long-term outcome of conservative treatment. ANZ J Surg 87(12):1011–1014

    Article  PubMed  Google Scholar 

  23. Felder SI, Barmparas G, Lynn J, Murrell Z, Margulies DR, Fleshner P (2013) Can the need for colectomy after computed tomography-guided percutaneous drainage for diverticular abscess be predicted? Am Surg 79(10):1013–1016

    Article  PubMed  Google Scholar 

  24. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG (2011) The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 54(6):663–671

    Article  PubMed  Google Scholar 

  25. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8:336–341

    Article  PubMed  Google Scholar 

  26. Shea BJ, Reeves BC, Wells G et al (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 358:j4008

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 355:i4919

    Article  PubMed  PubMed Central  Google Scholar 

  28. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13

    Article  PubMed  PubMed Central  Google Scholar 

  29. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ. 327:557–560

    Article  PubMed  PubMed Central  Google Scholar 

  30. Alvarez JA, Baldonedo RF, Bear IG, Otero J, Pire G, Alvarez P, Jorge JI (2007) Presentation, management and outcome of acute sigmoid diverticulitis requiring hospitalization. Dig Surg 24(6):471–476

    Article  PubMed  Google Scholar 

  31. Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F (2005) Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 48(4):787–791

    Article  PubMed  Google Scholar 

  32. Aquina CT, Becerra AZ, Xu Z, Justiniano CF, Noyes K, Monson JRT, Fleming FJ (2019) Population-based study of outcomes following an initial acute diverticular abscess. Br J Surg 106(4):467–476

    Article  CAS  PubMed  Google Scholar 

  33. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE (2003) Spectrum of disease and outcome of complicated diverticular disease. Am J Surg 186(6):696–701

    Article  PubMed  Google Scholar 

  34. Brandlhuber M, Genzinger C, Brandlhuber B, Sommer WH, Müller MH, Kreis ME (2018) Long-term quality of life after conservative treatment versus surgery for different stages of acute sigmoid diverticulitis. Int J Color Dis 33(3):317–326

    Article  Google Scholar 

  35. Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA (2006) Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 49(10):1533–1538

    Article  CAS  PubMed  Google Scholar 

  36. Bridoux V, Antor M, Schwarz L, Cahais J, Khalil H, Michot F, Tuech JJ (2014) Elective operation after acute complicated diverticulitis: is it still mandatory? World J Gastroenterol 20(25):8166–8172

    Article  PubMed  PubMed Central  Google Scholar 

  37. Detry R, Jamez J, Kartheuser A, Zech F, Vanheuverzwijn R, Hoang P, Kestens PJ (1992) Acute localized diverticulitis: optimum management requires accurate staging. Int J Color Dis 7(1):38–42

    Article  CAS  Google Scholar 

  38. Edna TH, Jamal Talabani A, Lydersen S, Endreseth BH (2014) Survival after acute colon diverticulitis treated in hospital. Int J Color Dis 29(11):1361–1367

    Article  Google Scholar 

  39. Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA (2010) Patterns of recurrence in patients with acute diverticulitis. Br J Surg 97(6):952–957

    Article  CAS  PubMed  Google Scholar 

  40. Elagili F, Stocchi L, Ozuner G, Dietz DW, Kiran RP (2014) Outcomes of percutaneous drainage without surgery for patients with diverticular abscess. Dis Colon Rectum 57(3):331–336

    Article  PubMed  Google Scholar 

  41. Elagili F, Stocchi L, Ozuner G, Kiran RP (2015) Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess. Tech Coloproctol 19(2):97–103

    Article  CAS  PubMed  Google Scholar 

  42. Etzioni DA, Chiu VY, Cannom RR, Burchette RJ, Haigh PI, Abbas MA (2010) Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum 53(6):861–865

    Article  PubMed  Google Scholar 

  43. Garfinkle R, Kugler A, Pelsser V, Vasilevsky CA, Morin N, Gordon P, Feldman L, Boutros M (2016) Diverticular abscess managed with long-term definitive nonoperative intent is safe. Dis Colon Rectum 59(7):648–655

    Article  PubMed  Google Scholar 

  44. Gregersen R, Andresen K, Burcharth J, Pommergaard H-C, Rosenberg J (2018) Long-term mortality and recurrence in patients treated for colonic diverticulitis with abscess formation: a nationwide register-based cohort study. Int J Color Dis 33(4):431–440

    Article  Google Scholar 

  45. Hachigian MP, Honickman S, Eisenstat TE, Rubin RJ, Salvati EP (1992) Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 35(12):1123–1129

    Article  CAS  PubMed  Google Scholar 

  46. Harisinghani MG, Gervais DA, Maher MM, Cho CH, Hahn PF, Varghese J, Mueller PR (2003) Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases. Radiology. 228(3):701–705

    Article  PubMed  Google Scholar 

  47. Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ, Konyalian VR (2006) Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis Colon Rectum 49(2):183–189

    Article  PubMed  Google Scholar 

  48. Lambiase RE, Deyoe L, Cronan JJ, Dorfman GS (1992) Percutaneous drainage of 335 consecutive abscesses: results of primary drainage with 1-year follow-up. Radiology. 184(1):167–179

    Article  CAS  PubMed  Google Scholar 

  49. Lambrichts DPV, Bolkenstein HE, van der Does DCHE, Dieleman D, Crolla RMPH, Dekker JWT, van Duijvendijk P, Gerhards MF, Nienhuijs SW, Menon AG, de Graaf EJR, Consten ECJ, Draaisma WA, Broeders IAMJ, Bemelman WA, Lange JF (2019) Multicentre study of non-surgical management of diverticulitis with abscess formation. Br J Surg 106(4):458–466

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Macias LH, Haukoos JS, Dixon MR, Sorial E, Arnell TD, Stamos MJ, Kumar RR (2004) Diverticulitis: truly minimally invasive management. Am Surg 70(10):932–935

    Article  PubMed  Google Scholar 

  51. Nelson RS, Ewing BM, Wengert TJ, Thorson AG (2008) Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg 196(6):969–974

    Article  PubMed  Google Scholar 

  52. Occhionorelli S, Zese M, Tartarini D et al (2016) An approach to complicated diverticular disease. A retrospective study in an Acute Care Surgery service recently established. Ann Ital Chir 87(6):553–563

    PubMed  Google Scholar 

  53. Pappalardo G, Frattaroli FM, Coiro S et al (2013) Effectiveness of clinical guidelines in the management of acute sigmoid diverticulitis. Results of a prospective diagnostic and therapeutic clinical trial. Ann Ital Chir 84(2):171–177

    PubMed  Google Scholar 

  54. Park HC, Chang MY, Lee BH (2010) Nonoperative management of right colonic diverticulitis using radiologic evaluation. Color Dis 12(2):105–108

    Article  Google Scholar 

  55. Pautrat K, Bretagnol F, Huten N, De Calan L (2007) Acute diverticulitis in very young patients: a frequent surgical management. Dis Colon Rectum 50(4):472–477

    Article  PubMed  Google Scholar 

  56. Poletti PA, Platon A, Rutschmann O, Kinkel K, Nyikus V, Ghiorghiu S, Morel P, Terrier F, Becker CD (2004) Acute left colonic diverticulitis: can CT findings be used to predict recurrence? AJR Am J Roentgenol 182(5):1159–1165

    Article  PubMed  Google Scholar 

  57. Saini S, Mueller PR, Wittenberg J, Butch RJ, Rodkey GV, Welch CE (1986) Percutaneous drainage of diverticular abscess: an adjunct to surgical therapy. Arch Surg 121(4):475–478

    Article  CAS  PubMed  Google Scholar 

  58. Schechter S, Eisenstat TE, Oliver GC, Rubin RJ, Salvati EP (1994) Computerized tomographic scan-guided drainage of intra-abdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery. Dis Colon Rectum 37(10):984–988

    Article  CAS  PubMed  Google Scholar 

  59. Siewert B, Tye G, Kruskal J, Sosna J, Opelka F (2006) Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 186(3):680–686

    Article  PubMed  Google Scholar 

  60. Subhas G, Rana G, Bhullar J, Essad K, Mohey L, Mittal VK (2014) Percutaneous drainage of a diverticular abscess should be limited to two attempts for a resilient diverticular abscess. Am Surg 80(7):635–639

    Article  PubMed  Google Scholar 

  61. Trenti L, Kreisler E, Galvez A, Golda T, Frago R, Biondo S (2015) Long-term evolution of acute colonic diverticulitis after successful medical treatment. World J Surg 39(1):266–274

    Article  PubMed  Google Scholar 

  62. van de Wall BJM, Draaisma WA, Consten ECJ, van der Kaaij RT, Wiezer MJ, Broeders IAMJ (2013) Does the presence of abscesses in diverticular disease prelude surgery? J Gastrointest Surg 17(3):540–547

    Article  PubMed  Google Scholar 

  63. You K, Bendl R, Taut C, Sullivan R, Gachabayov M, Bergamaschi R (2018) Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively. Br J Surg 105(8):971–979

    Article  CAS  PubMed  Google Scholar 

  64. Feingold D, Steele S, Lee S et al (2014) Practice parameters for the treatment of sigmoid diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum 57:284–294

    Article  PubMed  Google Scholar 

  65. Fozard JBJ, Armitage NC, Schofield JB, Jones OM ACPGBI Position Statement on Elective resection for diverticulitis. Color Dis 201 l;13(Suppl.3):1–11

  66. National Institute for health and Care Excellence. NICE Guideline. Diverticular disease: diagnosis and management. Draft for consultation, June 2019.

Download references

Code availability

N/A.

Author information

Authors and Affiliations

  1. The Countess of Chester Hospital, Chester, UK

    Hayley Fowler, Dale Vimalachandran & Rachael Clifford

  2. Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Suite D-361, Taylor Pavilion, 100 Woods Rd, Valhalla, NY, 10595, USA

    Mahir Gachabayov & Roberto Bergamaschi

  3. Section of Colon and Rectal Surgery, Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA

    Guy R Orangio

Authors
  1. Hayley Fowler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mahir Gachabayov
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dale Vimalachandran
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rachael Clifford
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Guy R Orangio
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Roberto Bergamaschi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Each author has contributed to the following aspects: (1) Concept of the work; study design; data collection, analysis, and interpretation; (2) writing the manuscript and/or its critical revision; (3) final approval of the submitted version; (4) all authors agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Roberto Bergamaschi.

Ethics declarations

Ethics approval

Ethical approval was not required given the summary design of the study.

Consent to participate

Consent to participate was not required given the summary design of the study.

Consent for publication

Consent for publication was not required given the summary design of the study.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Presentations: None.

Hayley Fowler and Mahir Gachabayov shared first authorship.

Supplementary Information

ESM 1

(DOC 63 kb)

ESM 2

(PDF 333 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fowler, H., Gachabayov, M., Vimalachandran, D. et al. Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review. Int J Colorectal Dis 36, 1367–1383 (2021). https://doi.org/10.1007/s00384-021-03899-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-021-03899-6

Keywords

Search

Navigation