Nonoperative Management of Perforated Diverticulitis With Extraluminal Air Is Safe and Effective in Selected Patients

BACKGROUND: The optimal treatment for diverticulitis with extraluminal air is controversial. OBJECTIVE: The purpose of this research was to evaluate the safety and effectiveness of nonoperative treatment of acute diverticulitis with extraluminal air. DESIGN: This was a retrospective cohort. SETTINGS: The study was conducted at an academic teaching hospital functioning as both a tertiary and secondary care referral center. PATIENTS: All of the patients with CT-diagnosed acute perforated diverticulitis with extraluminal air from 2006 through 2010 were included in this study. INTERVENTIONS: Nonoperative treatment composed of intravenous antibiotics, bowel rest, and percutaneous drainage were the included interventions. MAIN OUTCOME MEASURES: The need for operative management and mortality were measured. RESULTS: A total of 132 patients underwent nonoperative treatment, whereas 48 patients were primarily operated on. Patients treated nonoperatively were divided into 3 groups on the basis of identified factors that independently predicted risk for failure: 1) patients with pericolic air (n = 82) without abscess had a 99% success rate with 0% mortality. 2) Patients with distant intraperitoneal air (n = 29) had a 62% success ratewith 0% mortality. Abundant distant intraperitoneal air and fluid in the fossa Douglas were identified as risk factors for failure. Patients without these risk factors had an 86% success rate with nonoperative management. 3) Patients with distant retroperitoneal air (n = 14) had a 43% success rate with 7% mortality. LIMITATIONS: Comparison of nonoperative versus operative treatment cannot be made because of the study's retrospective nature. CONCLUSIONS: Nonoperative treatment of acute diverticulitis with extraluminal air is safe and effective in patients with a small amount of distant intraperitoneal air or pericolic air without clinical signs of peritonitis.