Evidence-based surgery: diverticulitis--a surgical disease?

Sigmoid diverticulitis is an increasingly common disorder. While there is no gender difference, the incidence increases with age. Many reports have been published on the topic, but there is no consensus on certain aspects of treatment. We conducted a literature search covering the past 30 years and report our own data. Two major areas of controversy exist. One concerns indications for elective surgery for symptomatic diverticulitis. The consensus is that there is no indication for prophylactic surgery. The first attack should be treated conservatively; elective surgery is considered following a second attack, but in immunocompromised patients earlier. The second controversy concerns surgical strategy in peritonitis from perforation. Three-stage operations have generally been abandoned. The question is whether to perform a sigmoid resection with primary anastomosis. One end of the spectrum is recent perforation which can be treated safely by resection and anastomosis. The other end is advanced feculent peritonitis in high-risk patients. In this situation a Hartmann procedure is recommended. Although data from prospective randomized studies are lacking, there seem to be indicators in the individual situation that allow a rational selection of the appropriate procedure. Diverticulitis can thus be treated surgically for a broad range of its forms of presentation.