Evaluation of current surgical management of acute inflammatory diverticular disease.

During the period 1980 to 1987, 127 patients were admitted with acute complications of diverticular disease; clinically diagnosed as acute diverticulitis in 86, peritonitis in 33 and colonic obstruction in eight. In those patients diagnosed as acute diverticulitis, conservative treatment was effective in 73 (85%), the other 13 requiring surgery. Of 31 patients, with a clinical diagnosis of peritonitis who underwent operation, 19 (61%) had free purulent or faecal fluid at laparotomy and the remainder had a localised phlegmonous mass. Sigmoid resection was performed in 34 patients and nonexcisional surgery in 18. In the earlier period of the study, there was a preference for the former procedure in patients with peritonitis rather than those with phlegmonous diverticulitis (63% vs 28%), and in the later period of the study, resection was the preferred treatment in both groups (91% vs 93%). The increase in resectional surgery significantly reduced mortality, at completion of treatment, in patients with peritonitis (P less than 0.05) but not in those with phlegmonous diverticulitis. There was an additional benefit of resection in the lower number of procedures per patient (1.5 vs 2.1), a lower median total hospital stay (32 days vs 50.5, P less than 0.01) and a lower wound infection rate (16% vs 32%, P less than 0.01) at the end of treatment. The optimum surgical approach at laparotomy for acutely complicated diverticular disease would therefore appear to be a resectional procedure. Of the patients operated on for 'peritonitis', 39% were found to have a localised diverticular mass/phlegmon. This group of patients, if identified earlier, may respond to conservative management in the first instance, and highlight an area where further improvements in management may be possible.