Traditionally, elective colon resection was recommended for young people (age younger than 50 years)

after one documented episode of uncomplicated diverticulitis. This recommendation was based on the

belief that DD is more virulent in young patients. However, data are conflicting in this regard. There

have been reports of young patients increased risk of complicated disease at presentation, increased

frequency of recurrences (in the same time period as older patients, not as a function of longevity), and

higher risk of needing emergency surgery and colostomy. Recommendation for elective resection

following a single episode of uncomplicated diverticulitis in patients younger than 50 years of age was

motivated by an interest in avoiding a colostomy and avoiding major morbidity and mortality. In view

of conflicting data and adoption of technical strategies for avoiding end-colostomies in all patients,

Nelson et al. have suggested following the same guidelines that are used for older patients.63,77–83

10 Immunocompromised patients are more likely to fail medical management and must be watched

closely since the manifestations of failure may be more subtle than in immunocompetent patients.

Transplant patients, those on steroids or chemotherapy, diabetics, and dialysis patients are at risk.

Elective resection in anticipation of transplant is also considered in some patients with DD.

Interestingly, human immunodeficiency virus (HIV)-positive patients with normal CD4 counts appear to

behave as if they were immunologically normal with respect to the incidence of diverticulitis and its

clinical course. Since HIV infection has principally been an illness of younger people, most studies of

diverticulitis have not included a large number of HIV-positive patients.84 That may change as longevity

improves with current antiretroviral regimens.

SUMMARY

DD is common and includes a spectrum of presentations and anatomic locations, favoring the left colon

in Western societies. The etiology is likely multifactorial, with a low-residue diet being a common

factor. The CT scan has dramatically improved diagnostic accuracy and helped with treatment planning.

Treatment often parallels the Hinchey stage, particularly the modified Hinchey classification. Surgical

treatment has evolved to favor medical management and image-guided percutaneous drainage of

abscesses when feasible to convert surgical emergency–staged procedures into either single-stage

procedures or procedures with primary anastomosis and diverting loop stoma. The distinction of

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complicated DD and colon cancer can be difficult, but early contrast enema studies or colonoscopy can

be safely performed and are the most helpful diagnostic procedures in this setting. The indications for

elective resection following successful medical management of DD are being reconsidered, and it is

becoming clear that elective sigmoid resection for DD should be offered to avoid recurrent symptoms,

not primarily to avoid free perforation and the need for an emergent colostomy. Minimally invasive

surgery is state of the art, and the hand-assisted techniques are particularly useful for elective DD

resections.

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