As a result of these and other data, the colorectal surgical specialists published an EBG in 2000 in which they concluded that the procedure of choice for perforated diverticulitis was a HP[23]. However, with the recognition up to half of the patients who underwent a HP never had their colostomy reversed and that colostomy closure was a morbid procedure, many colorectal surgeons performed a primary anastomosis in select cases. Primary resection with anastomosis (PRA) A 2006 meta-analysis [that included 15 case series (13 retrospective)]

indicated that mortality was significantly lower and there was a trend towards fewer surgical complications in patients who underwent PRA with or without a proximal diverting loop ileostomy compared those who underwent a HP for perforated diverticulitis [24]. Again, while this review Blasticidin S molecular weight suffers from a selection bias where the less healthy patients were more likely to undergo a HP, it does Epoxomicin solubility dmso document that emergency PRA in select patients has a low anastomotic leak rate (~6%) and that in the sicker patients (stage > II subset) PRA and HP had equivalent mortality (14.0 vs. 14.4%). Additionally, it was recognized that

85% of patients with PRA and proximal loop ileostomy had subsequent stomal closure [25]. As a result of these data, the colorectal surgical specialists updated their EBG in 2006 and recommended emergent definitive sigmoid resection for perforated diverticulitis with peritonitis but concluded that an acceptable alternative to the HP (i.e. MK-2206 colostomy) is primary anastomosis [26]. The precise role of proximal ileostomy diversion after PRA remains unsettled. Laparoscopic lavage and drainage (LLD) Interestingly, as the colorectal surgical specialists progressively endorsed a more aggressive approach, starting in 1996, there have been 18 case series involving Carnitine dehydrogenase 806 patients that document surprisingly better outcomes with simple LLD[27, 28].

In 2008 Myers et al. reported the largest series to date with compelling results (Figure 1) [29]. Out of 1257 patients admitted for diverticulitis over seven years, 100 (7%) had peritonitis with evidence of free air on x-ray or CT scan. These patients were resuscitated, given a third generation cephalosporin and flagyl and then taken emergently to the OR for laparoscopy. Eight were found to have stage IV disease and underwent a HP. The remaining 92 patients underwent LLD. Three (3%) of these patients died (which much lower than reported for PRA or HP). An additional two patients had non-resolution, one required an HP, and the other had further PCD. Overall, 88 of the 92 LLD patients had resolution of their symptoms. They were discharged to home and did not undergo an elective resection. Over the ensuing 36 months, there were only two recurrences. Another recent study by Liang et al. associates supports LLD[30].