Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis.

Abstract

Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous drainage followed by delayed resection. Controversy has arisen regarding the necessity of elective surgery, when nonoperative management has successfully resolved the index attack. The aim of this systematic review was to analyze the literature to determine the recurrence rate in those patients who were successfully managed nonoperatively and determine the role of elective surgical resection. An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews performed from 1986 to 2014. The search terms used were as follows: "diverticulitis," "abscess," "diverticular abscess," "percutaneous drainage," and "surgery." Studies included for review evaluated the management of diverticular abscesses and the subsequent role of delayed elective resection. All of the studies were systematically reviewed and underwent a meta-analysis. End points were the need for surgery and recurrent attacks without surgery. Twenty-two studies reporting a total of 1051 patients with acute diverticulitis with abscess formation (modified Hinchey grades IB and II) were included in the review. Percutaneous drainage was successful in 49% patients (diameter, >3 cm) and antibiotic therapy in 14% patients. Urgent surgery during the index hospitalization was performed in 30% of patients, elective resection in 36%, and no surgery in 35%. Recurrence rates were high, with 39% in patients awaiting elective resection and 18% in the nonsurgery group, with an overall recurrence rate of 28%. Of the whole cohort, only 28% had no surgery and no recurrence during follow-up. Sample size, heterogeneity, selection and treatment bias, and limited follow-up of included studies were limitations to this study. The evidence from the literature is weak but still suggests that complicated diverticulitis with abscess formation is associated with a high probability of resective surgery, whereas conservative management may result in chronic or recurrent diverticular symptoms.