Managing Perforated Diverticulitis: An Overview of Treatment Trends and Clinical Outcomes at a Single Centre in the United Kingdom.

Abstract

Introduction Perforation represents the most critical manifestation of complicated diverticulitis. In 2008, it was estimated that about 2,000 cases of perforated diverticulitis (PD) were diagnosed in the United Kingdom (UK). Management of PD is evolving with considerable variation in approaches between hospitals and countries with an increased trend towards a conservative approach. Objective Our aim is to provide a comprehensive overview of the management strategies and treatment outcomes for PD, with a particular focus on the influence of abscess size and the presence of distant air (DA) on the success of conservative management. Methods Data from 112 patients admitted with PD to a single district hospital in the UK between 2013 and 2018 were retrospectively analysed. CT scan reports and images were examined to assess the size and number of abscesses, as well as the presence of DA. Failed initial management was defined as the need for an alternative therapeutic option after 48 hours during the index admission or readmission within 12 weeks. Follow-up data were also reviewed to evaluate the need for elective resection and stoma reversal. Result In this cohort of 112 patients with PD, a variety of treatment strategies were employed. Antibiotic therapy alone was successful in 46 patients (41%). Radiological management was successful in only six patients (5%). Surgical washout was required in 12 cases (11%), while resection was performed in 40 cases (36%). Best supportive care was provided to eight patients (7%) who were considered unfit for invasive interventions. The success rate was higher in cases with smaller abscesses and no DA (p <0.05). Specifically, 30 out of 45 patients (66.6%) with abscesses less than 4 cm and no DA were managed successfully with conservative treatment, whereas the success rate dropped to 14 out of 30 patients (47%) when DA was present (p<0.05). For abscesses larger than 4 cm, the success rate was seven out of 20 patients (35%) without DA and significantly lower at two out of 20 patients (10%) with DA (p=0.01). The data also show a shift towards increased conservative management over the six-year period, with a steady reduction in the number of surgical interventions. However, 12 patients (19%) were readmitted with complicated diverticulitis after the initial non-resectional management. Conclusion We observed a shift towards more conservative, non-operative management of acute complicated diverticulitis with perforation over the six-year period, likely influenced by advancements in diagnostic and interventional radiology, antibiotic therapy, and minimally invasive techniques. Our data also stress that cases of PD with distant extraluminal air or larger abscesses are less suited to conservative treatment, often necessitating traditional surgical interventions. Long-term follow-up showed a moderate rate of readmissions after non-resectional management, and while stoma reversal was successful in a proportion of patients, many either opted to live with the stoma or were deemed unsuitable for reversal. A larger, multicentre prospective study would likely provide more robust data on this subject.