Hot topics in acute colonic diverticulitis: a narrative review

Acute diverticulitis represents a heterogeneous clinical condition whose management has significantly evolved over the past decades. The traditional paradigm of routine surgical intervention has progressively shifted toward a more tailored, patient-centered approach integrating non-operative strategies, interventional radiology, and selective surgery. This narrative review, based on current literature and expert discussion from an international symposium, aims to summarize the most relevant "hot topics" in the management of diverticulitis, particularly in complicated forms. Conservative treatment remains the cornerstone for selected patients with early-stage disease, supported by accurate clinical and radiological stratification. Antibiotic therapy has also evolved, with increasing emphasis on shorter treatment courses and antimicrobial stewardship. The management of specific radiological findings, such as pericolic extraluminal air, has been refined, supporting non-operative approaches in stable patients while highlighting the importance of correct staging. Interventional radiology plays a key role in the treatment of diverticular abscesses, allowing effective sepsis control and reducing the need for emergency surgery. In the surgical field, the choice between Hartmann's procedure and primary anastomosis is now driven by patient-related factors rather than disease stage alone, while laparoscopic peritoneal lavage and damage control surgery represent alternative strategies in selected scenarios. Technical controversies, including vascular ligation, extent of resection, and intraoperative adjuncts, remain unresolved, particularly in emergency settings. Elective surgery has shifted from a rule-based to a quality-of-life-driven indication, emphasizing shared decision-making. Finally, robotic surgery is emerging as a feasible option in selected patients, although its role remains limited by logistical and organizational factors. Overall, the management of acute diverticulitis requires a multidisciplinary, individualized approach aimed at balancing short-term safety with long-term functional outcomes.