Conservative Management of Perforated Diverticulitis in Adults: An Updated Systematic Review of Outcomes

The management of perforated diverticulitis (PD) has shifted over the last decade, moving from aggressive surgery toward non-operative strategies for hemodynamically stable patients. However, the safety of non-operative treatment in cases with extraluminal air, particularly Hinchey Ia-II disease, remains debated. This systematic review evaluates the efficacy, safety, and long-term outcomes of non-operative management for PD and identifies radiologic predictors of treatment failure.

A systematic review was conducted per PRISMA 2020 guidelines. PubMed/MEDLINE, Europe PMC, Science Direct, EBSCO Open Dissertations, ClinicalTrials.Gov, and Cochrane Library were searched for cohort studies published between 2015 and 2025. Inclusion criteria were adults with CT-confirmed PD (Hinchey I-II) treated non-operatively. The primary outcome was treatment success (survival without emergency surgery); secondary outcomes included recurrence, readmission, and mortality. Study quality was assessed using the Newcastle-Ottawa Scale (NOS).

Twelve cohort studies comprising 25 064 patients were included. Success rates ranged from 76% to 96% for contained perforations. Distant extraluminal air (DA) was a key predictor of failure, with success falling to 10%-37% compared to > 85% for isolated pericolic air. Other risk factors included abscess diameter > 4 cm, free fluid, and age > 75 years. Mortality declined over time (from 18.6% to < 5%), coinciding with increased colorectal subspecialist involvement. Recurrence rates remained notable (16.5%-37.5%), with most occurring after one year.

Non-operative management is a safe, effective first-line option for stable patients with PD, especially those with isolated pericolic air. Patients with DA or large abscesses are at higher risk of failure and require close monitoring or early intervention.