Surgeons navigate a complex decision-making process when treating patients with diverticulitis, a reality driven by new data that have enhanced clinicians’ understanding of this disease.
In Sunday’s session, “Controversies in the Management of Diverticulitis,” panelists described approaches that consider both patient preferences and clinical factors to help surgeons provide individualized treatment plans for their patients.
“This panel is made up of experts from across the US with expertise in the technical aspects and basic biology of diverticular disease,” said comoderator Najjia N. Mahmoud, MD, FACS, from the University of Pennsylvania in Philadelphia. “Insights into the hows and whys regarding etiology and treatment are essential when considering our therapeutic options.”
A range of contrasting views continues to surround the management of diverticulitis, which results in approximately 300,000 hospitalizations annually. One particularly contentious issue addressed by panelists: should patients with acute diverticulitis be managed by acute care/general surgeons or by colorectal surgeons?
According to Alexander T. Hawkins, MD, MPH, FACS, from Vanderbilt University Medical Center in Nashville, Tennessee, on the acute care/general surgery side, these clinicians provide round-the-clock availability and rapid decision-making skills, particularly in rural and community hospitals where colorectal surgeons may not be present. Unfortunately, these surgeons have variable exposure to newer minimally invasive and nonoperative approaches, and they have limited long-term follow-up continuity with patients.
On the colorectal surgery side, these clinicians have “subspeciality training in minimally invasive and restorative procedures and possess evidence-based elective resection decision-making,” said Dr. Hawkins. Unfortunately, there are access disparities, as these specialists are not always available for an urgent case, especially outside tertiary centers.
One notable solution to this debate is a hybrid model. “We’re better together. Acute care can be used for initial stabilization/emergency surgery, while colorectal surgery can be used for elective, complex, and follow-up care. We should focus less on who does it and more on best practices,” Dr. Hawkins said, adding that suggesting a new emphasis on collaboration, shared protocols, and regionalization where feasible.
For whoever conducts the initial surgery, he offered “key pearls,” including:
- Only operate if there is no alternative
- Use the minimally invasive approach if possible
- Perform anastomosis (with or without diversion)
- Leave the splenic flexure
- Tack the rectum up and out of the pelvis
Dr. Hawkins noted that patients are seeking three elements from their care: safe acute care in emergency scenarios, minimalization of permanent stomas, and clarity on long-term recurrence and quality of life.
The role of antibiotics also was a focus of this session. This approach has “always been the mainstay of treatment for Hinchey stage II, III, and IV,” said Ben Shogan, MD, FACS, noting that Hinchey stage I continues to be a source of debate for the treatment of certain patient subgroups.
Dr. Shogan described the findings in four key studies: AVOD, DIABOLO, STAND, and DINAMO, and outlined their limitations and caveats, including (depending on the study): limited exclusion criteria, higher resection rates, lack of efficacy benefit, limited power to detect clinical outcomes, and unequal accrual.
“Controversy thrives where data are lacking,” explained Dr. Mahmoud. “Diverticulitis is one of the most common problems we treat, yet randomized trials are exceptionally difficult to conduct in this disease. We must rely on expertise and experience, historical data, and increasingly, the potential of basic science to elucidate and give insight into the causes. I am hopeful that genetics and biology will give us a new way to identify those at greatest risk for severe disease and a way to predict the outcomes of our interventions.”
In June 2025, a task force within the Society of American Gastrointestinal and Endoscopic Surgeons Colorectal Surgery Committee was formed to develop a white paper on the topic of antibiotic omission in the management of acute uncomplicated diverticulitis. According to Dr. Shogan, the paper provides updates to patient selection criteria, how to counsel a patient regarding this approach, and suggestions for implementing hospital antibiotic omission policies.
“There is high-level evidence to avoid antibiotics for patients with uncomplicated diverticulitis who are not overly sick or carry significant comorbidities,” Dr. Shogan said. “I have changed my practice based on these recommendations. Antibiotics should be a part of the treatment in all other cases.”
Practical guidance regarding technical issues associated with colostomy closure and reversal and elective sigmoid resection also were addressed by panelists.
Ultimately, panelists provided context and an enhanced interpretation of emerging data to help establish more consistent treatment parameters for this patient population.
“There is always a need for a discussion on diverticulitis—the issues around it are controversial and the rate of diverticulitis in our population is increasing,” Dr. Mahmoud said. “We need to work toward socializing these controversies and provide solutions and options for consideration in a way that uses the available evidence as much as possible.”
