The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. METHODOLOGY These guidelines are constructed on the platform of the previously published Practice Parameters for the Treatment of Sigmoid Diverticulitis published by the American Society of Colon and Rectal Surgeons (ASCRS) in 2014.1 A systematic search was conducted under the guidance of an information services librarian. This search strategy is outlined under the search appendices (see Supplemental Digital Content, https://links.lww.com/DCR/B209). The PubMed, EMBASE, Cochrane, and Web of Science databases were searched from January 1, 2013, until October 26, 2019. Relevant manuscripts identified by individual authors were also included. Key word combinations using the MeSH terms including “Diverticulitis,” “Diverticulosis,” “Diverticular,” “Colonic,” “Colon Diverticulosis,” “Surgery,” “Medical Therapy,” “Antibiotics,” “Probiotics,” “Laparoscopic Lavage,” “Mesalamine,” “Rifaximin,” and “Surgery” were performed. The search was limited to English language abstracts with human subjects. A directed search of references embedded in the candidate publications was also performed. Emphasis was placed on prospective trials, meta-analyses, systematic reviews, and practice guidelines. Peer-reviewed observational studies and retrospective studies were included when higher-quality evidence was insufficient. In brief, a total of 4885 unique journal titles were identified. Initial review of the search results led to the exclusion of 4223 titles based on irrelevance of the title or because they consisted of a case report, letter to the editor, or nonsystematic review. A review of the remaining 662 titles included assessment of the full-length articles. This led to exclusion of an additional 494 titles for which similar but higher-level evidence was available. The remaining 168 titles were considered for grading of the recommendations (Fig. 1). The final source material used was evaluated for the methodological quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).2 When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to publication. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee. The submission was peer-reviewed by Diseases of the Colon & Rectum and the final recommendations were approved by the ASCRS Executive Council. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline and the authors have declared no competing interests related to this material.TABLE 1.: The GRADE System: grading recommendationsFIGURE 1.: PRISMA literature search flow sheet.The terms uncomplicated and complicated diverticulitis, symptomatic uncomplicated diverticular disease (SUDD), and recurrent diverticulitis are used throughout this document. For purposes of this guideline, complicated diverticulitis is defined as diverticulitis associated with uncontained, free perforation with a systemic inflammatory response, fistula, abscess, stricture, or obstruction. Micro-perforation with small amounts of contained, extraluminal gas, in the absence of a systemic inflammatory response, is not considered complicated diverticulitis. Uncomplicated diverticulitis is defined as diverticulitis that is not associated with any of the aforementioned features.3 Symptomatic uncomplicated diverticular disease is defined as diverticulosis with associated chronic abdominal pain in the absence of clinically overt colitis.4 Meanwhile, the term recurrent diverticulitis has no universally accepted definition and the studies reviewed in this guideline used and defined recurrence differently. STATEMENT OF THE PROBLEM The prevalence of diverticular disease has risen steadily in industrialized nations over the past few decades.5,6 A 2016 study using data from the National Inpatient Sample estimated that the prevalence of hospitalization for diverticulitis increased from 74.1 of 100,000 in 2000 to a peak of 96.0 of 100,000 in 2008.7 These authors found that there were 2,151,023 hospitalizations for diverticulitis during this time period with an average of 195,548 admissions per year.7 Another study compiled data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey and found that in 2010 there were more than 2.7 million discharges in the ambulatory setting associated with a diagnosis of diverticular disease, and that in 2012 there were more than 340,000 associated with a diagnosis of diverticulitis and of these patients were was associated with a of of and a of treatment of The authors used updated data from the same 2 and estimated that in there were million patients with diverticular disease in the ambulatory Another demonstrated that the of from to per 100,000 and and that the of these was in of diverticulitis has have recommendations for the clinical management of these with diverticular disease are as of to the for diverticulitis from in to in In patients are the of patients an per for diverticulitis from of 100,000 to of 100,000 and there has an in the use of and in the management of This the treatment for patients with diverticulitis. diverticular disease can any of the on and of disease, to the management of patients with diverticulitis, are the of these guidelines and are addressed in ASCRS clinical practice OF The of a patient with diverticulitis should a and and of recommendation based on related to diverticulitis and or are for fistula, and per is for and abdominal can be in the to when patients with diverticulitis and and have as of diverticulitis has as a of complicated diverticulitis in case in an to a that can patients who have complicated of the are small and the in retrospective study of patients with of diverticulitis, uncomplicated from complicated diverticulitis and the of and free on was associated with a of In a study of demonstrated that was to patients with uncomplicated and complicated Another study of patients demonstrated that was associated with diverticulitis a uncomplicated diverticulitis from complicated diverticulitis as was abdominal and this a for complicated diverticulitis of studies are to the of in the setting of diverticulitis the limited evidence not a management of the and is the in the assessment of diverticulitis. of recommendation based on has a to diverticulitis, disease and a treatment or is and specific for for abdominal including diverticulitis as as that can the associated with diverticulitis abscess, fistula, and extraluminal and and can patients to The of the diagnosis of the grade of on with the of of management in the term and with as the of and the of and and can be in the of a patient with diverticulitis when is not available or is of recommendation based on and be in patients with a can be or in can be to of pain that can diverticulitis when the diagnosis is in can complicated diverticulitis and should not be the this is is included as a in the practice guidelines of is and in patients be can also be in patients in is and be than from OF patients with uncomplicated diverticulitis can be of recommendation based on high-quality the use of has the treatment for patients with diverticulitis. 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