What are the AGA and WGO guidelines for elective surgery for diverticulitis?

Updated: Aug 06, 2019
  • Author: Elie M Ghoulam, MD, MS; Chief Editor: BS Anand, MD  more...
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Answer

The decision to proceed with elective surgery, typically at least 6 weeks after recovery from acute diverticulitis, should be made on a case-by-case basis. [5]  The 2015 American Gastroenterological Association (AGA) guidelines suggest against elective colonic resection in patients with an initial episode of acute uncomplicated diverticulitis. [5]  As recommended by the 2007 World Gastroenterology Organisation (WGO) guidelines, this decision should include consideration of the age and medical condition of the patient, the frequency and severity of attacks, and the presence of any persistent symptoms after the acute episode. [5]  Other appropriate indications for elective colectomy include an inability to exclude carcinoma, following an episode of complicated diverticulitis treated nonoperatively, or after percutaneous drainage of a diverticular abscess. [1]

Note the following:

  • Regarding attack frequency, after one attack of acute diverticulitis, about one third of patients will have a second attack. After a second episode, a further one third will have yet another attack. According to the 2007 WGO guidelines, a repeat episode requires immediate surgery if complications occur, such as free perforation, obstruction, abscess that is not resolved by percutaneous drainage, fistulas, and failure to respond to treatment. [1]

  • Regarding disease severity, most patients who present with complicated diverticulitis do so at the time of their first episode. Therefore, once a patient's initial presentation has been determined to be uncomplicated or complicated, the patient's future episodes are likely to follow a similar course.

  • A one-stage surgical approach with resection and primary anastomosis is often possible in elective settings because the disease is well localized and/or significantly resolved. The bowel must be well vascularized, nonedematous, tension free, and well prepared. The proximal margin should be an area of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third of the rectum where the taenia coalesce. Not all of the diverticula-bearing colon needs to be removed, as diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.

  • Patients with Hinchey stage I or II disease can usually have preoperative bowel preparation.


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