Clinical Research Directory

Management of Acute Complicated Diverticulitis: An Assessment of Current Practices

Acute complicated diverticulitis (ACD) is a frequent surgical emergency that can be life-threatening. It encompasses various clinical entities, including colonic perforations, abscesses (Hinchey II), fistulas, and purulent or fecal peritonitis (Hinchey III/IV). Historically, the Hartmann procedure (HP) was established as the standard of care for diffuse peritonitis, particularly in frail patients. However, this intervention is associated with high rates of permanent stomas, long-term complications, and impaired quality of life. Over the past decade, several randomized controlled trials (RCTs) have compared HP with sigmoid resection and primary anastomosis (PA), sometimes combined with a diverting ileostomy. Results from these studies, notably the LADIES and DIVERTI trials, indicate that in hemodynamically stable and immunocompetent patients, PA is associated with superior functional outcomes, fewer late complications, and higher stoma reversal rates. Other minimally invasive approaches, such as laparoscopic peritoneal lavage for Hinchey III, have also been explored, showing promise in reducing stomas and reinterventions. However, their efficacy relies on stringent patient selection, and their use is not recommended by current guidelines (e.g., HAS 2017) due to higher reintervention rates. Recent epidemiological data suggest a trend toward reducing emergency surgical interventions in favor of more conservative strategies in selected cases, such as initial medical management followed by elective surgery. In this context of diversifying therapeutic options, choosing the optimal treatment requires a delicate balance between efficacy, morbidity, mortality, quality of life, and long-term preservation of intestinal function. Despite these advances, several questions remain, particularly regarding patient selection criteria and the real-world long-term impact of these interventions. A potentially underestimated factor is the role of the operator, as a significant portion of emergency cases (nights and weekends) are handled by surgeons in training. Primary Objective: To provide a comprehensive overview of current management strategies for acute complicated diverticulitis by identifying preferred therapeutic modalities (conservative management, emergency surgery, delayed surgery) at the HUB (Hôpital Universitaire de Bruxelles). Secondary Objectives: To evaluate the adherence of these therapeutic approaches to international guidelines. To identify clinical and context-specific predictive factors influencing the choice of therapeutic strategy.

The Diverticulitis Study

Acute colonic diverticulitis is when a part of the colon gets swollen and inflamed. The diagnosis is based on a CT scan, which can show thickening of the colonic walls and infiltration of the diverticula. These changes and the concomitant symptoms can overlap with colorectal cancer (CRC). Therefore, the guidelines suggest that people with diverticulitis should be offered a colonoscopy to ensure, that CRC is not the underlying cause of the changes and symptoms. In Denmark, a lot of people get hospitalized each year due to diverticulitis, and many of them end up having colonoscopies with the purpose of excluding CRC. Currently, there are no methods for guiding colonoscopies following a diverticulitis episode, resulting in numerous unnecessary colonoscopies each year. In the Diverticulitis study, we want to investigate if a simple blood test analyzed for the presence of circulating tumor DNA (ctDNA), can help us decide who needs a colonoscopy. We will collect blood samples from 220 people with diverticulitis and categorize them into ctDNA positive and negative groups. The ctDNA category will be compared to the colonoscopy results to see if there is a correlation between being ctDNA positive and having a CRC diagnosed at the colonoscopy. This study could change clinical practice since we anticipate that ctDNA-guided triaging of diverticulitis patients is a cost-effective strategy for selecting diverticulitis patients needing colonoscopy, ensuring detection of the underlying CRC, and significantly reducing the number of patients undergoing unnecessary colonoscopy.