The future management of diverticular disease. A movie shot together rather than a photo taken by one specialist.

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Management of diverticular disease (DD) remains a point of debate. To investigate the current opinion of participants of the 2nd International Symposium on Diverticular Disease, on real-life management of patients with DD of the colon. Twelve questions were aimed at the diagnosis, treatment, and management options for diverticulosis and symptomatic DD. In total, 115 surveys from 8 European Countries were filled out. High fiber diet was widely prescribed in diverticulosis (59.1%). Probiotics (25%) were the most frequent prescribed drug, whereas 29.8% of participants did not prescribe any treatment in diverticulosis. Colonoscopy was frequently prescribed in symptomatic patients (69.3%), whereas 72.9% of participants did not prescribe any instrumental tool in their follow-up. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs both in symptomatic patients (28.1, 14.9%, and 11.4%, respectively) and to prevent recurrence of the disease (42.5%, 12.4%, and 28.2%, respectively). With respect to laboratory exams, 57.9% of participants prescribed them during follow-up. The majority of participants (64.9%) managed suspected acute diverticulitis at home. Rifaximin, probiotics, and mesalazine were the most frequent prescribed drugs to prevent recurrence of the disease (32.2%, 13.2%, and 11.4%, respectively), whereas 25.4% of participants did not prescribe any drugs. Finally, no differences were found among gastroenterologists, surgeons, and general practitioners in managing this disease. This surveys shows that current management of DD is similar between different medical specialities, generally in line with current literature.

Background: Diverticular disease of the colon is common in the Western world. With the first episode of diverticulitis, most patients will benefit from medical therapy, but in 10% to 20% of cases some complications will develop, such as intra-abdominal abscesses, obstructions, fistulas. In these conditions it is important to define the most appropriate surgical approach. Discussion: The management of diverticular disease has been successful owing to the advances in diagnostic methods, intensive care and surgical experience, but there is debate about the best treatment for some conditions. Fistulas complicating diverticulitis are the result of a localized perforation into adjacent viscera. In particular, the connection between the colon and the urinary tract is a serious anatomical abnormality that must be urgently corrected before a serious urinary infection results. Indications, timing and surgical procedures are determined by the severity of the disease and the patient’s general condition. Summary: Diverticular disease can lead to many complications. One of the most difficult to correct is an internal fistula, such as a colo-vesical fistula. The correct approach in cases where the disorder is clinically suspected has always been controversial, and the guidelines for sigmoid diverticulitis have not established the most appropriate method for diagnosis and treatment. At present, the surgical strategy for these cases requires interruption of the fistula and resection to remove the inflamed colonic segment, with or without primary anastomosis, focusing attention on the construction of the anastomosis to well vascularized and anatomically healthy tissues. It is clear, therefore, that establishing guidelines is difficult, because many pathological situations may be related to diverticulitis, and so, as our experience shows, the surgical approach has to be tailored to the patient’s general and local condition.

Diverticulosis leads to significant morbidity and mortality and is increasing in prevalence worldwide. In this paper, we review the clinical features, diagnosis, and management of diverticular disorders, followed by a discussion of recent updates and changes in the clinical approach to diverticular disease. Recent literature suggests that antibiotics are likely not necessary for low-risk patients with acute uncomplicated diverticulitis, and not all patients with recurrent diverticulitis require colectomy. Dietary restrictions do not prevent recurrent diverticulitis. Visceral hypersensitivity is increasingly being recognized as a cause of persistent abdominal pain after acute diverticulitis and should be considered along with chronic smoldering diverticulitis, segmental colitis associated with diverticula, and symptomatic uncomplicated diverticular disease. Clinicians should be aware that traditionally held assumptions regarding the prevention and management of diverticular disorders have recently been called into question and should adjust their clinical practice accordingly.

Over the last decade there has been a striking shift in our understanding of the epidemiology, pathology, and management of diverticular disease. Indeed, many of the guidelines published in the late nineties and early 2000s are now redundant. High-fiber diets, avoidance of nuts and seeds, antibiotic treatment for mild diverticulitis, elective resection after 2 attacks of diverticulitis, Hartmann's procedure (HP), and aggressive management of young patients are all open to question. The more we challenge our understanding of diverticulitis it becomes apparent how little we know about this disease entity. This review aims update the reader on current hypotheses and evidencebased modern management strategies in diverticular disease.

To date, the appropriate management of diverticular disease is still controversial. The American Society of Colon and Rectal Surgeons declared that the decision between conservative or surgical approach should be taken by a case-by-case evaluation. There is still lack of evidence in literature about long-term outcomes after elective sigmoid resection for diverticular disease. Considering the potentially key role of the surgical technique in long-term outcomes, there is the need for surgeons to define strict rules to standardize the surgical technique. Currently there are 5 areas of debate in elective surgery for diverticular disease: laparoscopic versus open approach, the site of the proximal and distal colonic division, the vascular approach and the mobilization of the splenic flexure. The purpose of this paper is to review existing knowledge about technical aspects, which represent how the surgeon is able to affect the long-term results.

Role of dietary fibre in older adults with asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD): Systematic review and meta-analysis

Chronic thromboembolic pulmonary disease (CTEPD) with or without pulmonary hypertension (PH) is an important potential consequence of venous thromboembolic disease. Untreated CTEPD with pulmonary hypertension (CTEPH) is associated with high rates of morbidity and mortality. Several treatment options are now available for patients with CTEPD and CTEPH, including pulmonary endarterectomy (PEA), balloon pulmonary angioplasty, medical therapyor a combination of therapies. Choice of treatment depends on the location of the thromboembolic disease burden, presence and severity of PH and patient factors, including frailty, parenchymal lung disease and other comorbidities. PEA is a complex surgery that can result in excellent outcomes and resolution of disease, but also comes with the risk of serious perioperative complications. This manuscript examines the history of PEA and its place in Australasia, and reports on outcomes from the main Australasian CTEPH expert centre. It provides a summary of up-to-date guidance on how PEA should be utilised in the overall management of these patients and describes opportunities and challenges for the future diagnosis and management of this disease, particularly in the Australasian setting.

Diagnóstico y tratamiento de la enfermedad diverticular del colon derecho: revisión de conjunto

Background/Objectives: Diverticular disease (DD) affects a significant portion of the aging population and is increasingly linked to gut microbiota alterations. Probiotics have emerged as a potential adjunct therapy, particularly in managing symptoms and inflammation. The evidence for the recommended use of probiotics in clinical practice for management of diverticular disease is still a matter of controversy. Methods: A comprehensive literature search was conducted across five major databases up to October 2024. Eligible studies included randomized controlled trials (RCTs) and observational studies assessing probiotic use in adult patients with diverticular disease. Results: Thirteen studies met the eligibility criteria. Probiotic therapy was associated with improvement in abdominal pain (SMD 0.63; 95% CI: 0.38-0.88). For bloating, probiotics demonstrated a small trend toward improvement (SMD 0.158; 95% CI: -0.107 to 0.422), although this did not reach statistical significance. C-reactive protein (CRP) outcomes were reported in three studies conducted in acute uncomplicated diverticulitis. All showed reductions in CRP following probiotic therapy; however, substantial variability in baseline levels and assessment timepoints prevented a reliable pooled estimate, and findings were summarized descriptively. Long-term outcomes from two RCTs showed a reduced risk of recurrence (RR 0.22; 95% CI: 0.095-0.510), with multi-strain and longer-duration regimens appearing more beneficial. Conclusions: Probiotics, particularly multi strain formulations administered over longer durations, may help improve symptoms and reduce inflammatory activity in diverticular disease; however, the certainty of evidence remains low to very low due to heterogeneity and methodological limitations. Larger, high-quality randomized trials are needed to clarify the long-term clinical impact of probiotic therapy.

This review examines the role of colonoscopy in the evaluation of asymptomatic diverticulosis, segmental diverticular disease-associated colitis and acute diverticulitis. Asymptomatic acute diverticulitis, discovered during screening colonoscopy, is also discussed. In addition, the use of colonoscopy, both diagnostic and therapeutic, is compared to standard radiology studies for the management of acute diverticular bleeding.

The management of diverticular disease and its complications are an increasing burden to the health system. The natural history of conservatively managed diverticular abscesses (Hinchey I and II) is poorly described and it remains open to debate whether subsequent sigmoid resection is indicated after conservative management. This observational study compares outcomes of patients treated with conservative management (antibiotics +/- percutaneous drainage) and surgery. All patients admitted at Christchurch Hospital with diverticulitis between 1 January 1998 and 31 December 2009 were recorded in a database. A retrospective analysis of patients with an abscess due to complicated diverticulitis was undertaken. Initial management, recurrence and subsequent surgery were recorded. The patients were followed until 1 January 2014. Of 1044 patients with diverticulitis, 107 with diverticular abscess were included in this analysis. The median age was 66 ± 16 and 60 were male. All patients had sigmoid diverticulitis and were diagnosed with a computed tomography. The median abscess size was 4.2 ± 2.1 cm. During median follow-up of 110 months, the overall recurrence rate was 20% (21/107). Recurrence varied according to initial treatment; namely antibiotics (30%), percutaneous drainage plus antibiotics (27%) and surgery (5%) (P = 0.004). The median time to recurrence was 4 ± 11.7 months, and most recurrences were treated conservatively; four patients underwent delayed surgery. Recurrence after diverticular abscess is higher after initial conservative treatment (antibiotics +/- percutaneous drainage) compared with surgery, however, patients with recurrent disease can be treated conservatively with similar good outcomes and few patients required further surgery.

Resection of the perforated segment: A significant advance in treatment of diverticulitis with free perforation or abscess

Diverticular disease (DD) is one of the most common benign gastrointestinal conditions in the Western world, with a range of clinical manifestations from uncomplicated symptoms to acute complications requiring surgery. Elective sigmoidectomy is indicated in cases of Complicated Diverticular Disease (CDD) after recovery, Symptomatic Uncomplicated Diverticular Disease (SUDD), and Recurrent Diverticulitis (RD). This study aims to assess the short- and long-term outcomes of a standardized surgical approach for DD. A retrospective analysis was conducted on 442 patients who underwent elective sigmoidectomy or left hemicolectomy for DD disease between January 2012 and March 2020. Different DD scenarios were included: 128 patients with SUDD (29%), 170 with RD (38.5%), 144 with CDD (34.0%). All patients had nearly 5 years of follow-up. Preoperative evaluations included computed tomography (CT) scans and colonoscopy. Surgical procedures followed a standardized protocol, including medial to lateral approach, inferior mesenteric artery preservation, distal resection at the level of the upper rectum with a 60 mm blue Endo Gia cartridge, an end-to-end Knight-Griffen anastomosis with a 29 mm circular stapler and Indocyanine Green (ICG) testing. Demographic data, type of DD, surgical technique, and postoperative outcomes were recorded. The primary outcome measures included intraoperative details, complication rates, recurrence rates, and quality of life (GastroIntestinal Quality of Life Index [GIQLI] scores) at 1 and 5 years post-surgery. The cohort included 240 males and 202 females with a median age of 50 years. The surgical procedure was standardized across all patients. The mean operative time was 121 ± 28 minutes, with a conversion rate of 5.2% and an overall complication rate of 16.1%. Major complications, including anastomotic leaks, were observed in 4.9% of patients. The mean hospital stay was 4 days. Diverticulitis recurrence occurred in 5.2% of patients, more frequently in those with a disease duration of more than 5 years (p = 0.028). Cox regression analysis revealed that the duration of DD greater than 5 years was the only significant risk factor for diverticulitis recurrence (Hazard Ratio [HR] 2.42, 95% CI 1.12 to 4.62, p = 0.028). GIQLI scores significantly improved 1 year after surgery (92.7 ± 9.5 vs 97.8 ± 8.5, p < 0.001) and continued to improve at 5 years (92.7 ± 9.5 vs 118.1 ± 10.6, p < 0.001). Elective sigmoidectomy for DD, using a standardized laparoscopic technique, is safe and effective, with low complication rates and significant long-term improvement in quality of life. The recurrence rate of diverticulitis is low, and surgery provides lasting relief, especially for patients with recurrent or complicated forms of the disease. Standardization appears essential to optimize safety and efficacy in DD management.