Challenges and Complexities in the Management of Acute Diverticulitis

Abstract

The aim of this thesis was to explore a few select challenges in the management of patients with acute diverticulitis (AD). This was done by undertaking 3 retrospective studies utilising the 13-year experience of management of patients with AD in a tertiary hospital in Sydney. The focus was on the identification of tools that predict failure of conservative management, the assessment of success of surgical management strategies in these patients, and exploring if these strategies are/should be different in a vulnerable group of patients. The data demonstrated the utility of C-reactive protein (CRP), an acute phase reactant, in the dynamic assessment of response to therapy in patients managed non-operatively. By stratifying the cohort into 4 groups based on their CRP trajectory, we demonstrated that patients with a rising trajectory are more likely to fail conservative therapy and require intervention. In patients who were managed operatively, patients who had a resection followed by primary anastomosis (PA), with or without a defunctioning stoma, had similar morbidity to patients who underwent a Hartmann’s procedure (HP). This echoes the available literature in the field. We also demonstrated that there was a temporal change in the rate of PA as the evidence in the literature on the safety of PA strengthened and that more experienced colorectal surgeons were more likely to undertake this procedure. In patients with immunosuppression who present with uncomplicated AD, conservative management appears safe, however, this subgroup of patients is more likely to undergo surgical management if they are immunosuppressed and are also more likely to have complications post-operatively. This again echoes the available literature and strengthens the call for conservative management of patients with uncomplicated AD.