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.

Study Overview

• Status: Completed
• Conditions: Colonic Diverticulitis; Acute Complicated Diverticulitis

• Study Type: Observational
• Enrollment (Actual): 208

Contacts and Locations

Study Locations

• Belgium
  • Brussels Capital
    • Anderlecht, Brussels Capital, Belgium, 1070
      • Institut Jules Bordet

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Patients older than 18 years who were treated for acute complicated diverticulitis between January 1, 2015 and December 31, 2024 at Erasme Hospital and Institut Jules Bordet.

Description

Inclusion Criteria:

• Patients presenting with a first episode or recurrence of acute complicated diverticulitis.
• CT scan confirmation of a Hinchey stage ≥ Ib (including stages Ib, II, III, and IV) at admission.
• Initial management performed within the HUB (Hôpital Universitaire de Bruxelles) network.
• Hospital admission between January 1, 2015, and December 31, 2024.

Exclusion Criteria:

• Uncomplicated acute diverticulitis, defined by a CT scan Hinchey stage of 0 or Ia.
• Patients in whom the diagnosis of acute diverticulitis was ultimately ruled out during medical chart review.
• Patients whose initial management occurred at another hospital facility (outside the HUB network).
• Incomplete medical records preventing the reliable extraction of clinical or follow-up data.

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Distribution of management strategies for acute complicated diverticulitis.	Percentage of patients treated by each of the following strategies: exclusive medical treatment, radiological drainage, immediate emergency surgery, rescue surgery following medical failure, or elective surgery.	From hospital admission up to 10 years (end of study period).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Surgical Procedure Type (Hartmann Procedure vs. Primary Anastomosis) based on Hinchey Classification and Clinical Status.	The study will evaluate the association between baseline clinical parameters (including age and immunosuppression status) and radiological severity, assessed by the Hinchey classification (stages Ib to IV on admission CT scan), with the final therapeutic choice. Logistic regression analysis will be used to identify independent predictors for: (1) failure of conservative treatment and (2) selection of surgical procedure type (Hartmann Procedure vs. Primary Anastomosis). Results will be reported as Odds Ratios (OR) with 95% Confidence Intervals.	Through study completion, an average of 14 days (duration of index hospitalization).
Success rate of conservative treatment for complicated diverticulitis.	Proportion of patients successfully managed without surgery during the index hospitalization.	During index hospitalization (average of 12.4 days).
Post-operative morbidity and mortality.	Percentage of patients with severe complications (Clavien-Dindo III-IV) and mortality rate at 30 days post-surgery.	30 days post-surgery.
Stoma reversal rate.	Percentage of patients who received a temporary stoma and successfully underwent surgical restoration of bowel continuity during the follow-up period.	Up to 10 years.
Evolution of the Rate of Laparoscopic Approach.	Percentage of patients undergoing a laparoscopic approach (including converted laparoscopies) compared to open surgery. The trend will be analyzed across three time periods (2015-2017, 2018-2020, 2021-2024) to assess the adoption of minimally invasive techniques.	Perioperative (during initial surgery).
Length of Hospital Stay (LOS).	Number of days from hospital admission to discharge. The median length of stay will be compared across the three time periods (2015-2017, 2018-2020, 2021-2024) to evaluate the impact of changing clinical practices.	From hospital admission to discharge (average 10-14 days).
Adherence to Guidelines Regarding Peritoneal Lavage.	Percentage of surgical cases where peritoneal lavage was performed as a standalone treatment (without resection). The evolution of this practice will be assessed across the three time periods to evaluate adherence to international guidelines (EAES/WSES) recommending the abandonment of this technique.	Perioperative (during initial surgery).

Collaborators and Investigators

• Sponsor: Jules Bordet Institute

Study record dates

Study Major Dates

• Study Start (Actual): December 1, 2025
• Primary Completion (Actual): March 30, 2026
• Study Completion (Actual): March 30, 2026

Study Registration Dates

• First Submitted: May 11, 2026
• First Submitted That Met QC Criteria: May 15, 2026
• First Posted (Actual): May 22, 2026

Study Record Updates

• Last Update Posted (Actual): May 22, 2026
• Last Update Submitted That Met QC Criteria: May 15, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Diverticular Diseases; Intestinal Diseases; Digestive System Diseases; Gastrointestinal Diseases; Colonic Diseases; Gastroenteritis; Diverticulosis, Colonic; Diverticulitis; Diverticulitis, Colonic
• Other Study ID Numbers: SRB2025380

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data (IPD) will not be shared in order to protect patient confidentiality and comply with European data protection regulations (GDPR) and institutional privacy policies.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No