Impact of Changing Guidelines on Elective Resection of Uncomplicated Diverticulitis in the United States

Abstract

Introduction

The incidence of diverticulitis has increased in recent years. Management strategies have shifted from routine elective colectomy after two episodes of uncomplicated diverticulitis to more individualized decision-making.

Objective

To evaluate the impact of updated management guidelines on trends and outcomes of elective colectomy for uncomplicated diverticulitis.

Methods

A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (2012–2019). Patients undergoing elective colectomy for uncomplicated diverticulitis were included. Exclusion criteria were complicated diverticulitis, emergent surgery, malignancy on final pathology, and ASA score of 5 or unknown. Emergent cases were analyzed only for temporal trends.

Results

From 2012 to 2019, elective colectomies for uncomplicated diverticulitis increased from 2,326 (96.7% elective) to 3,740 (98.9% elective) (p < 0.001). After excluding emergent cases, 25,045 patients were analyzed. Overall morbidity decreased from 16.4% to 10.7% (p < 0.001), and serious morbidity from 7.4% to 6.5% (p = 0.005). Other improvements included reductions in reoperation (4.2% to 3.5%), anastomotic leak (3.5% to 2.8%), wound infection (7.7% to 2.9%), transfusion (2.8% to 2.3%), shock/sepsis (3.1% to 2.4%), ileus (7.2% to 5.4%), and median length of stay (4 to 3 days). Operative time increased slightly (172 to 181 minutes, p = 0.002). Ostomy and mortality rates remained unchanged.

Conclusion

Despite guideline changes encouraging individualized management, elective colectomies for uncomplicated diverticulitis are increasing, with significantly improved postoperative outcomes, possibly due to better patient selection and surgical care.

Keywords

uncomplicated diverticulitis - elective colectomy - diverticulitis management guidelines

Introduction

Diverticulitis is a common and increasingly prevalent disease, leading to significant morbidity, hospitalizations, and healthcare costs.[1] Currently, it is still the leading indication for elective colectomy in the United States.[2] As its incidence rises, from 62 per 100,000 in 1998 to 76 per 100,000 in 2005, colorectal surgeons will face growing questions about the optimal management of recurrent uncomplicated cases of diverticulitis.[3] Historically, the American Society of Colon and Rectal Surgeons (ASCRS) recommended elective colectomy after two episodes of uncomplicated diverticulitis requiring hospitalization or a single episode of complicated disease. However, this guidance has evolved over the years.

After 2006, ASCRS released updated guidelines advocating for a more individualized, patient-centered approach in deciding to recommend surgery.[4] While elective colectomy remains recommended for complicated diverticulitis involving mesocolic abscesses >5cm or pelvic abscesses, fistula, obstruction, or stricture; the routine resection of recurrent uncomplicated cases is no longer advised.[5] [6] Instead, surgical decisions should be based on symptom burden, quality of life, and patient preference.[7]

Despite these changes, there is little data on how the updated guidelines have influenced surgical practice volume and outcomes. A logical deduction would be to assume that if patients are allowed to experience repeated episodes of diverticulitis, the volume of procedures performed would decline. Yet, this has yet to be demonstrated in the current literature. Another knowledge gap concerns whether delaying surgery in patients with recurrent inflammatory episodes results in more complex operative conditions and worse postoperative outcomes. Given the increasing incidence of diverticulitis, it is critical to understand whether these evolving recommendations are improving patient care or introducing unintended risks.

This study aimed to address these gaps by analyzing national surgical data to determine how ASCRS guideline changes have impacted the volume of elective colectomies and whether a more liberal approach to surgery has influenced perioperative outcomes. These findings will provide essential insight into the effect of evolving clinical guidelines on surgical decision-making and patient care.

Methods

Data Source

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database and procedure specific data was used to perform retrospective analysis. ACS-NSQIP is a nationally validated, risk-adjusted, outcomes-based database that collects more than 150 perioperative variables on patients undergoing surgery from over 700 participating member hospitals of varying size and academic affiliation. Certified surgical clinical reviewers prospectively collect data with the purpose of evaluating and improving surgical quality of care.[8] [9] This study has been approved by the Johns Hopkins School of Medicine Institutional Review Board.

Inclusion Criteria

Initially, all adult patients (18 years and older) who underwent elective and emergent colectomies for uncomplicated diverticulitis between 2012 and 2019 were included in this study. Emergent cases were tabulated to understand the temporal trend of colectomies. Emergent colectomies were excluded from the remainder of the statistical analysis. We intentionally omitted the years 2020 to 2022 to avoid any potential bias created by the COVID-19 pandemic. We used the following Current Procedural Terminology (CPT) codes for elective colectomy: 44140, 44144, 44145, 44146, 44204, 44207, 44208. We defined uncomplicated diverticulitis using the International Classification of Diseases (ICD) ninth and tenth revisions codes 562.11 (Diverticulitis of colon [without mention of hemorrhage]), K57.32 (Diverticulitis of large intestine without perforation or abscess without bleeding), and K57.33 (Diverticulitis of large intestine without perforation or abscess with bleeding). We excluded cases of complicated diverticulitis, emergent cases, and those with final pathology resulting in malignancy.

Baseline Characteristics of Patients

Demographic characteristics included age (<60, 60–74, >75 years), sex and race (White, Black, Other, Unknown). Baseline clinical characteristics included ASA classification (I − II, III, IV), obesity (body mass index [BMI] ≥30), smoking status, diabetes, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), hypertension, dyspnea, preoperative chronic steroid/immunosuppressive therapy, bleeding disorders and modified frailty index (0, 1, ≥2). The five-item modified frailty index is a previously validated patient frailty stratification measure that consists of five NSQIP variables: diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, hypertension, and partially/totally dependent functional status.[10]

Outcomes

The primary outcomes were 30- day postoperative overall and serious morbidity. Overall morbidity was defined as the occurrence of one or more of the following adverse events within 30 days post-operatively: wound infection, pneumonia, urinary tract infection(UTI), venous thromboembolism (VTE), cardiac complication, shock/sepsis, unplanned intubation, bleeding requiring transfusion, renal complication, on ventilator >48 hour, organ/space surgical site infection(SSI), and anastomotic leak. Serious morbidity was defined based on Clavien − Dindo Class III − IV (cardiac or renal complications, shock/sepsis, unplanned intubation, on ventilator >48-hour, organ/space SSI, or reoperation). Secondary outcomes included postoperative ileus, operating time, conversion to open procedure, hospital length of stay (LOS), 30-day postoperative readmission, and 30-day postoperative mortality. Reasons for reoperation and the procedures performed during reoperation were also obtained.

Statistical Analysis

Continuous variables are shown as medians with an interquartile range (IQR) and categorical variables are displayed as numbers with percentages. Pearson's Chi-squared test was used for categorical variables and Kruskal Wallis test was used for continuous variables. Note, emergent cases were included in evaluating trends to compare the proportion of emergent versus elective cases, ensuring that any trend changes were not a result of more sites participating in NSQIP over time. The emergent cases were excluded from the remainder of the analysis. Statistical significance was indicated by p < 0.05. All statistical analyses were performed using Stata, version 18.0 (StataCorp, College Station, Texas).

Results

Study Populations

Between the years 2012 to 2019, the number of colectomies performed on patients in our study population increased at a per year rate from 2,326 (9.3%) (96.7% elective vs 3.3% emergent) in 2012 to 3,470 (14.6%) (98.9% elective vs 1.1% emergent) in 2019 (p≤0.001) ([Fig. 1]). The utilization of minimally invasive approaches rose from 86.2% in 2012 to 92.9% in 2019 (p < 0.001). After excluding emergent cases, 25,045 patients were included in the study ([Fig. 2]). Of these patients, 56.28% were female and 85% were White. The median age was 58 (IQR 50 - 66) with 69.83% patients being less than 65 years old, and the median BMI was 28.89 (IQR 25.5–33.13). The demographic data are summarized in [Table 1].

Table 1 Demographic and Clinical Characteristics of Patients Undergoing Elective Colectomy for Uncomplicated Diverticulitis (NSQIP 2012-2019)

Characteristic, n (%)	Patients N = 25045
Age, median (IQR)	58 (50-66)
Age group, years
< 60	13,713 (54.8)
60-74	9,475 (37.8)
> 75	1,857 (7.4)
Sex
Male	10,950 (43.7)
Female	14,095 (56.3)
Race
White	21,502 (85.9)
Black	1,433 (5.7)
Other	251 (1.0)
Unknown	1,772 (7.0)
ASA classification
I-II	16, 195 (64.7)
III	8,621 (34.4)
IV	229 (0.9)
BMI >30	10, 583 (42.4)
BMI, median (IQR)	28.89 (25.5-33.1)
Current Smoker	4,469 (17.8)
Diabetes	2,440 (9.7)
CHF	38 (0.2)
COPD	687 (2.7)
Hypertension	10,800 (43.1)
Dyspnea	1,031 (4.1)
Steroid/Immunosuppressive Use	923 (3.7)
Bleeding Disorder	307 (1.2)
Frailty Category
0	13,332 (53.2)
1	9,277 (37.0)
> = 2	2,436 (9.7)

Abbreviations: ASA, American Society of Anesthesiologists; BMI, Body Mass Index; IQR, Interquartile Range, CHF, Congestive Heart Failure; COPD, Chronic Obstructive Pulmonary Disease

Fig. 1 Proportion of Elective vs Emergent Colectomies Performed for Diverticulitis (NSQIP 2012–2019).

Fig. 2 Study flowchart with inclusion and exclusion criteria (NSQIP 2012–2019).

Outcomes

The primary and secondary outcomes are illustrated in [Table 2]. The 30-day morbidity steadily decreased during the years studied. The overall morbidity was 16.4% in 2012 and decreased to 10.7% in 2019 (p≤0.001), with serious morbidities similarly decreasing, 7.4% to 6.5% (p = 0.005).

Table 2 30-Day Post-Operative Outcomes for Patients Undergoing Elective Colectomy for Uncomplicated Diverticulitis (NSQIP 2012-2019)

Outcome (%)	2012 2,326	2013 2,693	2014 3,125	2015 3,545	2016 3,021	2017 3,276	2018 3,319	2019 3,740	p
Overall morbidity[a]	382 (16.4)	391 (14.5)	464 (14.9)	442 (12.5)	318 (10.5)	356 (10.9)	341 (10.3)	401 (10.7)	<0.001
Serious morbidity[b]	173 (7.4)	184 (6.8)	220 (7.0)	239 (6.7)	157 (5.2)	198 (6.0)	183 (5.5)	244 (6.5)	0.005
Anastomotic leak	80 (3.5)	83 (3.1)	96 (3.1)	97 (2.7)	68 (2.3)	79 (2.4)	66 (2.0)	103 (2.8)	0.012
Wound infection	180 (7.7)	182 (6.8)	201 (6.4)	174 (4.9)	134 (4.4)	120 (3.7)	90 (2.7)	108 (2.9)	<0.001
Organ space SSI	80 (3.4)	97 (3.6)	104 (3.3)	117 (3.3)	86 (2.9)	108 (3.3)	97 (2.9)	144 (3.9)	0.35
Pneumonia	13 (0.6)	15 (0.6)	26 (0.8)	22 (0.6)	10 (0.3)	18 (0.6)	17 (0.5)	13 (0.4)	0.16
UTI	46 (2.0)	43 (1.6)	67 (2.1)	57 (1.6)	35 (1.2)	49 (1.5)	51 (1.5)	66 (1.8)	0.11
VTE	26 (1.1)	12 (0.5)	27 (0.9)	29 (0.8)	16 (0.5)	20 (0.6)	32 (1.0)	29 (0.8)	0.07
Cardiac	4 (0.2)	9 (0.3)	12 (0.4)	12 (0.3)	8 (0.3)	10 (0.3)	13 (0.4)	14 (0.4)	0.87
Shock	71 (3.1)	68 (2.5)	107 (3.4)	93 (2.6)	51 (1.7)	67 (2.1)	58 (1.8)	88 (2.4)	<0.001
Unplanned intubation	6 (0.3)	9 (0.3)	17 (0.5)	9 (0.1)	12 (0.4)	15 (0.5)	6 (0.2)	7 (0.2)	0.10
Bleeding requiring transfusion	66 (2.8)	80 (3.0)	85 (2.7)	90 (2.5)	45 (1.5)	60 (1.8)	71 (2.1)	84 (2.3)	0.001
Renal complications	9 (0.4)	13 (0.5)	11 (0.4)	14 (0.4)	13 (0.4)	16 (0.5)	20 (0.6)	18 (0.5)	0.88
On ventilator >24hrs	6 (0.3)	13 (0.5)	12 (0.4)	11 (0.3)	8 (0.3)	13 (0.4)	5 (0.2)	8 (0.2)	0.30
Ileus	166 (7.2)	204 (7.6)	206 (6.6)	242 (6.8)	160 (5.3)	167 (5.1)	173 (5.2)	202 (5.4)	<0.001
Readmission	165 (7.1)	192 (7.1)	256 (8.2)	244 (6.9)	191 (6.3)	228 (7.0)	205 (6.2)	266 (7.1)	0.08
Reoperation	97 (4.2)	105 (3.9)	115 (3.7)	138 (3.9)	83 (2.8)	100 (3.1)	96 (2.9)	131 (3.5)	0.18
Ostomy Formation	4 (0.2)	7 (0.3)	6 (0.2)	7 (0.2)	7 (0.2)	4 (0.1)	4 (0.1)	5 (0.1)	0.86
Mortality	3 (0.1)	4 (0.2)	9 (0.3)	7 (0.2)	4 (0.1)	4 (0.1)	3 (0.1)	4 (0.1)	0.54
LOS (IQR)	4 (3-6)	4 (3-5)	4 (3-5)	4 (3-5)	4 (3-5)	3 (3-4)	3 (2-4)	3 (2-4)	<0.001
Operative time, median (IQR)	172 (132-225)	177 (132-234)	179 (136-239)	178 (135-233)	179 (134-231)	180 (135-238)	179 (131-233)	181 (137-234)	0.002

Abbreviations: LOS, Length of Hospital Stay; SSI, Surgical Site Infection; UTI, Urinary Tract Infection; VTE, Venous Thromboembolism; IQR, Interquartile Range.

^a Overall morbidity: Wound infection, pneumonia, urinary tract infection, VTE, cardiac complication, shock/sepsis, unplanned intubation, bleeding transfusion, renal complication, on ventilator >48 hours, organ space SSI, and anastomotic leak.

^b Serious morbidity: Clavien-Dindo III-IV (cardiac complication, shock/sepsis, unplanned intubation, renal complication, on ventilator >48 hours, organ space SSI, and reoperation)

A specific breakdown of the outcomes compared year to year is listed in [Table 2]. There were statistically significant decreases from 2012 to 2019 in wound infections (7.7% versus 2.9%; p ≤0.001), post-operative shock/sepsis (3.1% versus 2.4%; p≤0.001), bleeding transfusion requirements (2.8% vs 2.3%; p = 0.001), post-operative ileus (7.2% versus 5.4%; p≤0.001), and median length of stay (4 [IQR 3–6] vs 3 days [IQR 2–4] days; p≤0.001). There was also a statistically significant increase in the median operative time (172 [IQR 132–225] vs 181 minutes [IQR137–234] minutes; p = 0.002). There was no significant increase in the rate of unplanned ostomy formation. Furthermore, no significant differences were found in cardiac, renal, or pulmonary events as well as post-operative venous thromboembolism, unplanned intubation/> 24 hours on a ventilator postoperatively, or sepsis.

Discussion

The intent of our study was to better understand the clinical impact of the change in guidance regarding elective surgical intervention for uncomplicated diverticulitis. The guidance from ASCRS prior to 2006 recommended elective colectomy after two episodes of diverticulitis. Since this time, there have been two updates to the clinical practice guidelines for the management of diverticulitis. In both iterations of the guidelines, there was repeated emphasis on a nuanced discussion regarding when to perform an elective colectomy between the surgeon and patient.[7] [11] This can be partially attributed to the natural history of uncomplicated diverticulitis and the inherit risk of recurrence. It has been shown that the recurrence rate for uncomplicated diverticulitis is 16–23%, with the incidence of complicated recurrent episodes that may require a stoma is also low, at ∼6%. With this information, current recommendations emphasize that selection criteria for elective surgery should be individualized according to the patient's symptomatology and severity of episodes, in addition to other factors.[12]

In this study, we evaluated the number of elective colectomies performed and the intraoperative and postoperative outcomes associated with these procedures. We suspected that the number of elective colectomies performed would decrease with a corresponding increase in overall and serious morbidity. The thought behind this hypothesis was that repeated bouts of inflammatory insults with continued nonoperative interventions for uncomplicated diverticulitis would lead to more technically challenging operations.

Previously, it has been documented that the number of elective colectomies performed for diverticulitis has increased since the change in guidelines in 2006 away from 2 episodes of diverticulitis necessitating a colectomy. Before the guideline change, elective surgeries increased steadily, rising from 1.8 to 2.6 surgeries per 100,000 adults between 2000 and July 2006, representing a 44% increase. After the guideline change, the growth rate still increased but at a slower pace by 0.06 surgeries per year. The rate of elective colectomies doubled in the 65–79 age group after the change.[13] While this data are helpful to understand the general landscape of surgery for diverticulitis, it does not separate those procedures performed for complicated episodes. ASCRS still recommends elective colectomy for complicated cases including abscesses, fistulas, and strictures_. [7] Despite guidelines that have shifted away from earlier surgical interventions, the number of elective colectomies performed for diverticulitis has increased since 2012 to 2019.

The serious and overall morbidity associated with these procedures decreased as well. In our study, elective colectomies were associated with a statistically significant decrease in the incidence of the most common complications in wound infections, post-operative shock, bleeding transfusion requirements, postoperative ileus, and median length of stay despite longer median operative time. This decrease is likely multifactorial. The shift away from elective open surgery and toward minimally invasive surgery (MIS) is certainly a factor. Multiple trials have illustrated superior short-term outcomes with laparoscopic when compared with an open approach in the elective setting.[14] This fact, coupled with the increasing comfort and competency of surgeons with MIS techniques, contributes to improved outcomes. It is of note that the increase in operative time was only 10 minutes longer in comparison from 2012 to 2019 and unlikely to have significant impact on the overall length of stay. Furthermore, perioperative care of colorectal patients has improved with the advent and implementation of the Enhanced Recovery After Surgery (ERAS) recommendations. Multiple meta-analyses and randomized controlled trials have shown that the ERAS pathway reduces the overall morbidity rate while shortening the hospital length of stay without an increased rate of readmission.[15]

Another important aspect of the nonoperative management of diverticulitis is the quality of life for these patients. There are several randomized control trials (RCT) and several retrospective studies comparing nonoperative versus surgical management of recurrent diverticulitis. Although these studies have smaller study populations, they demonstrated increased quality of life in patients who underwent elective surgery as opposed to conservative management.[16] [17] More randomized controlled trials (RCTs) and meta-analyses should be conducted to gain a better understanding of the less objective aspects of conservative diverticulitis management. However, this data, along with the findings from our study indicating a decrease in overall and serious morbidity, may encourage surgeons to feel more confident in recommending elective surgery.

Our study is not without limitations. First, the retrospective nature of the analysis using the NSQIP database inherently limits the ability to control for all potential confounding variables. Although NSQIP is a validated and comprehensive database, it relies on data that are subject to variability in reporting across institutions, which may influence the accuracy of outcomes such as postoperative complications. Furthermore, we excluded data from 2020 onward to avoid potential biases introduced by the COVID-19 pandemic. This exclusion prevents any examination of most recent trends or pandemic-related impacts on elective surgical volumes and outcomes. Another limitation is the absence of clinical data beyond what is available in NSQIP, such as patient comorbidities and exact severity or chronicity of diverticulitis episodes. This restricts our ability to fully understand individual patient characteristics that may influence the decision to proceed with elective resection. The decision-making process for elective colectomy in uncomplicated diverticulitis is, and should be, an individualized discussion. However, the NSQIP database does not capture the rationale behind clinical decisions. Therefore, the study cannot differentiate whether the increased rate of elective procedures is due to patient-specific factors, provider preferences, or institutional practices. Future studies with access to more specific data could provide further insights into these complex clinical decisions and offer more robust conclusions on guideline adherence and the drivers of improved outcomes.

Conclusion

There are no precise recommendations for when to intervene surgically on patients with recurrent uncomplicated diverticulitis. Our study demonstrates that despite recommendations centered on individualized discussions and not on the empiric number of episodes, surgeons in the United States are performing more elective colectomies for diverticulitis. We found no evidence that this approach leads to more difficult surgeries due to repeated inflammatory insults. In fact, our results suggest that the surgeries performed were safer with decreased overall and serious morbidity. While each discussion concerning elective colectomy should be patient-centered, this data can reassure surgeons in recommending elective colectomies for recurrent bouts of uncomplicated diverticulitis.

Conflict of Interest

None declared.

Source(s) of support and Acknowledgments

Mr. Edwin Lewis and The Nicholl Family Foundation provided generous support of the Johns Hopkins Division of Colorectal Surgery Research Fund. The authors would like to acknowledge the role of the Johns Hopkins Surgery Center for Outcomes Research (JSCOR) in supporting this study.

Meetings

Accepted for a poster presentation at the American Society of Colon and Rectal Surgeons Annual 2025 meeting, San Diego, CA, May 10–1, 2025, and Chesapeake Colorectal Society, Bethesda, MD, April 5, 2025.

Author Contributions

TKF wrote the original draft of the manuscript. TKF, SLG, and VJO conceptualized the project. MS contributed data curation, formal analysis, and project administration. VJO supervised the project. All other authors contributed to reviewing and editing the manuscript

• References

• 1 Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Gastroenterology 2009; 136 (03) 741-754
• 2 Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140 (07) 681-685
• 3 Munie ST, Nalamati SPM. Epidemiology and Pathophysiology of Diverticular Disease. Clin Colon Rectal Surg 2018; 31 (04) 209-213
• 4 Rafferty J, Shellito P, Hyman NH, Buie WD. Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49 (07) 939-944
• 5 Sartelli M, Weber DG, Kluger Y. et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020; 15 (01) 32
• 6 Roberts P, Abel M, Rosen L. et al; The Standards Task Force American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 1995; 38 (02) 125-132
• 7 Hall J, Hardiman K, Lee S. et al; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63 (06) 728-747
• 8 About ACS-NSQIP. American College of Surgeons. Accessed 15 November 2024. Available from: https://www.facs.org/quality-programs/acs-nsqip/about
• 9 ACS NSQIP Participant Use Data Files. American College of Surgeons. Accessed 15 November 2022. Available from: https://www.facs.org/quality-programs/acs-nsqip/participant-use
• 10 Chimukangara M, Helm MC, Frelich MJ. et al. A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surg Endosc 2017; 31 (06) 2509-2519
• 11 Feingold D, Steele SR, Lee S. et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57 (03) 284-294
• 12 Carr S, Velasco AL. Colon Diverticulitis. [Updated 2024 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541110/
• 13 Strassle PD, Kinlaw AC, Chaumont N. et al. Rates of Elective Colectomy for Diverticulitis Continued to Increase After 2006 Guideline Change. Gastroenterology 2019; 157 (06) 1679-1681.e11
• 14 Jecius H, Khurrum M, Krall E. et al. Emergent colectomy for colorectal cancer: A comparative analysis of open vs. minimally invasive approach. Am J Surg 2023; 225 (04) 724-727
• 15 Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2014; 38 (06) 1531-1541
• 16 van de Wall BJM, Stam MAW, Draaisma WA. et al; DIRECT trial collaborators. Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2017; 2 (01) 13-22
• 17 Santos A, Mentula P, Pinta T. et al. Comparing Laparoscopic Elective Sigmoid Resection With Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized Clinical Trial. JAMA Surg 2021; 156 (02) 129-136

Publication History

Received: 01 July 2025

Accepted: 01 October 2025

Article published online:
29 December 2025