How to Approach Purulent Perforated Diverticulitis?

Albert B. Lowenfels, MD


April 28, 2017

What is the preferred method for managing perforated diverticulitis conforming to the Hinchey grade III classification, namely purulent but not feculent fluid within the abdomen? To answer this question, the authors of a study published in the Annals of Surgery performed a meta-analysis of three randomized controlled trials.[1] Two of the studies were performed in Scandinavia while the third study was carried out in Europe.

Included in the study were 307 patients (age range, 60-69 years), of whom 159 underwent laparoscopic lavage and 148 underwent initial primary resection. The primary endpoint was the frequency of required early intervention within 30 days. On the basis of these criteria, patients with initial lavage fared worse: 28% versus 8.8% in the primary resection group (RR, 3.0; 95% CI, 1.2-7.9) required re-intervention within 30 days of the initial procedure.


This report provides additional information but does not solve the dilemma of managing patients with purulent perforated diverticulitis. Using the primary endpoint of early re-intervention, early intervention proved to be the best strategy. However, many of the re-interventions were only additional drainage procedures, often performed without general anesthesia.

Other secondary endpoints, such as 30- or 90-day mortality and presence or absence of a stoma, were not significantly different between the two groups. Moreover, the follow-up period was limited to 12 months—not really sufficient to tell us about long-term results.

Where does this report leave us? The best conclusion for now may be that although early intervention may eventually be better than drainage, we will have to wait for more evidence before reaching a firm conclusion.


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