Introduction

Once considered an elderly condition, diverticular disease and its most frequent complication, acute diverticulitis (AD), are spreading in younger population[1, 2] and increasing worldwide by a 3–9.5% [3,4,5] annual rate, with relevant morbidity and mortality [3], thus becoming a major issue for national health systems [6, 7].

AD may be a challenging condition, as clinical relevance varies widely, ranging from asymptomatic (or pauci-symptomatic) picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications and proposed management.

Differently from the late seventies, when Hinchey first proposed an intraoperative four-stage classification [8], AD diagnosis and severity assessment is presently performed preoperatively, with a pivotal role played by CT scan, both concerning severity assessment and differential diagnosis with colon cancer, eventually leading to the most appropriate management. Considering AD assessment, several authors [9,10,11,12,13] have tried to improve and translate Hinchey’s intraoperative classification in CT preoperative imaging, also including rarer conditions not listed in 1978 classification, including distant, non-pelvic abscesses [9, 11], stenosis [14], extraluminal air [10, 12] or fistula [13], potentially leading to various approaches, ranging from non-operative management, newly introduced specific procedures and surgical resection. Unfortunately, those classifications resulted as being often more descriptive than useful, and 1978 Hinchey’s one is still the most used classification of AD in clinical practice, although it is hampered by well-known “dark zones”, difficult to classify and to treat.

AD management is continuously evolving, too, both in mild cases as well as in severely affected patients. The improvement of antibiotic-regimens efficacy [15, 16], the development of increasingly effective imaging-guided techniques for mini-invasive, non-surgical drainage [17, 18], and the diffusion of laparoscopic technique also in an emergency setting [19, 20], are reshaping the way AD is approached nowadays, widening management options and multiplying the decision-making moments.

Recent guidelines by international scientific societies [21,22,23,24], try to throw some light in such a complex subject and provide recommendations allowing for a flexible management in clinical decision-making. Nevertheless, surveys based on national registry databases[25] show that clinical practice is not evolving as generally recommended, probably also owing to difficult AD multidisciplinary management in an emergency setting, unavailability of latest technology in peripheral hospitals, and an increasing trend towards defensive medicine by general surgeons during their duties.

The present survey is aimed at an appraisal of actual clinical practice in AD diagnosis and management in the early 2020s, in order to verify the real spread of recent recommendations and the progressive abandonment of nowadays unjustified behaviors. This 39-item questionnaire explores gray zones and unconsidered situations that can put the surgeon in difficulty, especially in emergency situations and when experience is still limited. For this reason, as a secondary purpose, the present analysis is aimed at identifying different attitudes associated with clinical experience, by stratifying survey responders in young (residents/within 5 years from residency) and expert surgeons.

Methods

The survey was carried out between November 2022 and February 2023 by the Colorectal Emergency Section of the Italian Society of Colorectal Surgery (SICCR) and the data were collected using an online questionnaire by Google Forms. This survey, named “Taboos in emergency colorectal surgery—Section: diverticulitis”, aims to explore surgeons’ attitude in diagnosis and management in “borderline" situations, either elective or in emergency, that are still not clearly identified by the currently available guidelines and recommendations. The purpose of the survey was explained to all respondents with a brief introduction and respondents were asked to sign a privacy policy consent on a voluntary basis. Both residents and certified surgeons with various experience in general and colorectal surgery were considered eligible for the survey.

The Wasvary classification, based on the CT findings and presented at the beginning of the survey was used through all the questionnaire di assess AD severity (Fig. 1).

Fig. 1
figure 1

Modified Hinchey classification by Wasvary et al. based on CT findings. CT computed tomography, AD acute diverticulitis

Full size image

Responders were invited to answer to a 33-item-questionnaire divided into eight sections: general information, workplace and personal experience in colorectal surgery (Q1–Q10); management of uncomplicated acute diverticulitis (Q11–Q12); management of complicated acute diverticulitis (Q13–Q17); imaging (Q18); elective colectomy (Q19); experience in workplace (Q20–Q21); colovescical fistula (Q22); Surgical technique and technical details of elective colonic resection (Q23–Q33) (Table 1).

Table 1 Questions of the survey
Full size table

Answering to all questions was mandatory to complete the survey. Survey distribution to surgeons took place through mailing lists, instant message services, and the official social media accounts of the Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colorettale, SICCR) on Facebook, Instagram, and LinkedIn. A reminder was mailed 2, 4 and 6 weeks after the first mailing. All respondents were informed that the results of the survey would have been used for further statistical evaluation and scientific publication. Anonymity was guaranteed by study design. After the closing date for questionnaire submissions, results were downloaded as a comma separated values (CSV) and analyzed by using Excel (Microsoft Corporation, Redmond, USA). Results of the survey were reported according to the Checklist for Reporting Results of Internet ESurveys (CHERRIES) guidelines [26].

Statistical analysis

Collected data were processed, and results were summarized as frequencies (n) and percentages (%), separately for each question. A further stratification of the outcomes was obtained dividing the responses into two classes of experience according to: number of colectomies performed (≤ 50 vs. ≥ 51) and years of experience (within 5 years from the end of residency program—residents included, vs. > 5 years). All the data were reported in contingency tables for subsequent inferencial analysis. Statistical analyses were performed using the commercial software “SPSS” (IBM SPSS Statistics for Windows [Version 28]. Armonk, NY: IBM Corp.), the open source statistical system “R” (R Core Team (2023). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL: https://www.R-project.org/), and the freeware package of statistical programs for epidemiologists “Winpepi” (Abramson, J. H. (2016). WinPepi: Computer programs for epidemiologists. [Version 11.65]. Retrieved from http://www.brixtonhealth.com/pepi4windows.html).

The contingency tables obtained from each question were analized using the Chi-squared test and the Fisher’s exact test, as appropriate, to assess the potential difference between experience groups. The results were considered statistically significant for a p value below 5% (p < 0.05).

Results

General information, workplace workload and personal experience in colorectal surgery

Four hundred and fifty-five questionnaires were correctly completed. After excluding 52 double reports from the same responders, questionnaires from 403 different respondents were considered eligible for the final analysis. Overall, 274 (68%) respondents were men and 128 (31.7%) women (1 was not specified). More than half of the interviewees work in University hospitals (211; 52.3%) (Fig. 2), of these only 73 (18.1%) worked in a hospital where less than 50 colectomies are performed per year (Fig. 3). The majority of expert surgeons (> 5 years of experience) are distributed between university hospitals (61/149; 40.9%) and public hospitals (72/149; 48.3%) while only 10.7% in affiliated private hospitals. The same trend occurs if we consider the respondents by number of colectomies performed. In most environments, an intensive care unit (390; 96.7%) and a regular activity of emergency surgery (354; 87.8%) and interventional radiology (298; 73.9%) were present (Table 2). Table 3 highlights the Italian working regions of the respondents to the survey, compared to SICCR members’ distribution.

Fig. 2
figure 2

Type of hospital. Distribution of the various hospital settings among the respondents

Full size image
Fig. 3
figure 3

No. of colectomies (unit) per year. Surgical activity in terms of numbers of colectomies performed per year in the respondents' centers

Full size image
Table 2 Setting of the hospital
Full size table
Table 3 Working regions of respondents
Full size table

Concerning surgical experience, more than half of interviewed surgeons (254; 63%) were still in their training program or within 5 years from the end of residency, whereas only 104 (25.8%) had more than 10 years of surgical experience (Table 4, Fig. 4). Seventy-five percent (302) had performed fewer than 50 colonic resections in their experience and 18.4% (74) had performed more than 200 laparoscopic procedures (Table 4, Fig. 5).

Table 4 Surgeon’s experience
Full size table
Fig. 4
figure 4

Personal experience (years). Years of experience among the respondents

Full size image
Fig. 5
figure 5

Surgeon’s experience. Number of colectomies performed among respondents

Full size image

Uncomplicated acute diverticulitis (Table 5)

Table 5 Uncomplicated acute diverticulitis (Wasvary Ia) management
Full size table

Dealing with the presented case of acute uncomplicated Wasvary Ia diverticulitis (Question 11), 13 (3.2%) surgeons opted for a conservative management without antibiotics, 167 (41.4%) opted for an outpatient management with oral antibiotics, while the remaining ones preferred an intravenous antibiotic therapy as inpatients with (147; 36.5%) or without (74; 18.4%) fasting. Concerning the preferred investigation to be performed to exclude the presence of colon cancer, almost all the interviewees chose colonoscopy, at 30 days (169; 41.9%) or 60 days (189; 46.9%), respectively. Only 39 (9.7%) of surgeons opted for CT with enema (Table 5). The statistical analysis highlighted how the most experienced surgeons (> 50 performed colectomies) express a prefer for enema colon-CT after 30 days (p = 0.002).

Complicated acute diverticulitis (Table 6)

Table 6 Complicated acute diverticulitis
Full size table

One-hundred-thirty-six (33.7%) of respondents identified 4 cm as the AD-related abscess’ minimum diameter needing to be drained, whereas it was 5 cm for 155 surgeons (38.5%), while it did not influence the decision-making process for 70 (17.4%). The comparative study between less ad more experienced surgeons showed that "5 cm cut-off" is more often preferred by the second ones both in terms of colectomies performed and number of years of experience (p < 0.001). When faced with a pelvic abscess non-drainable by radiology techniques, the majority chose a wait-and-see attitude (279; 69.2%), while 91 surgeons (22.6%) would proceed for laparoscopic “lavage and drainage”. Only 7 (1.7%) would opt for vaginal or rectal drainage, and most of these were among the less experienced respondents.

In the presence of radiological and clinical features of purulent diffuse peritonitis (Wasvary III), most of the interviewees (345; 85%) would approach the surgical exploration laparoscopically to confirm CT diagnosis. If a Wasvary III AD is confirmed at laparoscopy, 179 surgeons (44.4%) would perform lavage and drainage only, 75 (18.6%) laparoscopic resection-anastomosis with protective ostomy, and 39 (9.7%) laparoscopic Hartmann resection.

In the case on extraluminal gas (or “air bubbles”), almost all interviewees opted for hospitalization (385; 95.5%), with 112 (27.8%) carrying out a laparoscopic exploration while 273 (67.7%) would prefer a wait and see attitude by antibiotics IV administration and close clinical monitoring (Table 6).

Imaging (Table 7)

Table 7 Imaging
Full size table

Considering the preferred examination to confirm AD etiology in the case of a woman in her childbearing age presenting with the umpteenth episode and mild symptoms, 235 (58.3%) of the interviewees should choose CT scan, 141 (35%) would use ultrasound in expert hands, and 26 (6.5%) would opt for clinical examination alone without carrying out any further investigation (Table 7).

Elective colectomy (Table 8)

Table 8 Main indication for elective colectomy
Full size table

The main indication for delayed, elective colectomy was a significant worsening of perceived quality of life for 135 (33.5%) surgeons, a history of a complicated AD requiring the drainage for 106 (26.3%), whereas for 99 (24.6%) it was the absolute number of previous AD episodes. Fifty-one (12.7%) chose patient’s immuno-deficiency and 7 (1.7%) young age (Table 8).

Experience in your workplace (Table 9, Fig. 6)

Table 9 Unit and personal experience in severe acute diverticulitis
Full size table
Fig. 6
figure 6

Percentage of Hartmann’s resections/total emergency procedures for AD. Frequency of Hartmann procedures in the centers where respondents work

Full size image

Asked about the rate of Hartmann operations among all emergency procedures performed for AD at their hospital, 29% of surgeons answered ¼, 35.2% declared ½ and 25.8% reported ¾, with 9.9% of colleagues admitted that such a rate exceeded 90%.

One-hundred-fifteen (28.5%) responders stated that, in their environment, performing damage control surgery (DCS) in a hemodynamically unstable patient is not an option, and 76 (18.9%) declared that they have already performed such a procedure as operating surgeon (Table 9).

The comparison between the two classes of experience, revealed that DCS was more often performed by expert surgeons, both considering colectomies performed (p = 0.0014) and years of experience (p < 0.001).

Colovescical fistula (Table 10)

Table 10 Acute diverticulitis-related colovescical fistula’s management
Full size table

A colovescical fistula in a 70-year-old patient with mild dysuria, positive urine culture, and pneumaturia at CT is reported being mostly approached by colonic resection and anastomosis, without (140, 34.7%) or with (122, 30.3%) protective ostomy. Fifty (12.4%) surgeons would opt for an endoscopic management as first approach (with/without ostomy), 48 (11.9%) would prefer performing just a protective ostomy and re-evaluation at 6 months, while 32 (7.9%) would just wait and re-evaluate the patient at a 6-month-interval (Table 10).

Surgical technique and technical details (Table 11)

Table 11 Surgical technique and details
Full size table

Concerning elective colectomy technical details, more than ¾ of surgeons opted for a peripheral section of vessels (78.4%), a limited colonic resection (sigmoidectomy, 77.2%) and the colorectal anastomosis at/below the sacral promontory (78.9%). A systematic colonic splenic flexure mobilization was the choice of 58.3% of surgeons.

Among maneuvers aimed at checking colorectal anastomosis integrity, the hydropneumatic test and the check of anastomosis “rings” after mechanical stapling resulted as being performed by 93.1% and 95.8%, respectively, whereas ICG test was reported by 55.1% of surgeons (Table 11).

Discussion

Participants and participants’ facilities (Tables 2, 3, 4)

Four-hundred-three general surgeons/general surgery residents responded to the survey, with a 63% rate of young surgeons (within 5 years from residency program). Experience in both major colorectal resections and laparoscopic surgery reported by survey responders are consistent with the young age of most participants. The geographical distribution of participants is related to the numerosity of population in each Italian region as well as SICCR members distribution, with slightly higher rates of responders in Emilia-Romagna, Lombardia and Lazio, probably also owing to survey promotion activity by the authors.

Many responders’ hospitals are secondary–tertiary general hospitals, as only roughly 10% were private health facilities (41/403), only 12.2% without emergency surgery activity (49/403), and 18.1% (73/403) performing less than 50 colorectal resections per year. Interestingly enough, more than ¼ of responders’ hospitals (105/403) does not have interventional radiology unit available on site, which may be supposed to affect AD management, in particular, in the case of complicated cases associated with abscesses (Wasvary II).

The number of University hospitals seems over-represented as they account for more than 50% (211/403), whereas the majority of surgical facilities in Italy are non-University institutions. Such a finding seems related to the high rate of residents (149/403), mostly attending University hospitals, completing the survey.

AD management

Mild AD (Wasvary Ia) (Table 5)

As expected, the vast majority of surgeons favors antibiotic treatment of mild AD cases (Wasvary Ia), whereas it is remarkable that in almost 45% (180) an outpatient setting is adopted. This is consistent with the recent trend in management of non-severe AD cases as outpatients [21, 24]. Interestingly enough, more expert surgeons prefer to associate fasting at inpatients management.

Considering investigations aimed to exclude colorectal cancer after AD episode, colonoscopy (at a 30- or 60-day delay) remains the standard approach for the vast majority of surgeons, regardless of age or experience, while virtual-Colonoscopy (or contrast enema enhanced CT scan), a tool recently proposed by specialized centers for AD assessment [27,28,29], seems still a niche examination, more frequently preferred by expert colorectal surgeons (p = 0.002).

Pelvic abscess (Wasvary II) (Table 6)

About ¾ of the participants (291) indicates 4 or 5-cm-diameter the minimum abscess size needed to be drained by imaging-guided-approach. This appears to be consistent with recent literature [24, 30, 31]. The answer "diameter is not a factor", given by as many as 70 surgeons (17.5%), in our opinion should not be recommended, as general and local signs/symptoms may be mild or lack in the case of pelvic abscesses, which therefore could be undertreated. Surprisingly, the rate of this answer is significantly higher in so called expert surgeons (roughly ¼ for both colleagues with > 50 colectomies and > 5-year experience). Probably, such a finding may be supposed to be related to a more updated attitude by less experienced surgeons in such a challenging situation.

Pelvic abscess management after refused/unsuccessful imaging-guided drainage (Table 6)

In the absence of symptoms or with minor symptoms, a conservative attitude by fluid administration and antibiotic therapy, with reassessment at a 5–7-day interval, is preferred by most surgeons (69%, 279/403). In the case of surgical approach is preferred, a mini-invasive approach of wash and drain (W&D) avoiding major resections in an emergency setting prevails (91/122 undergoing surgery). This conservative and mini-invasive attitude seems to be in line with recent guidelines and, to some extent, confutes the hypothesis of an increasing “defensive” attitude, leading to an early intervention, by surgeons.

Purulent peritonitis (Wasvary III) (Table 6)

Surgical exploration is the choice of almost all participants (384/403, 95.3%), with about 10% (39/384) preferring laparotomy to laparoscopy. Considering this latter issue, interestingly enough, laparotomy is preferred by 12% of residents, 8% of young specialists, only 2% of moderately experienced surgeons (5–10 years from residency) and 11.5% among very experienced surgeons. Seemingly, a mid-generation of already experienced, laparoscopy-oriented surgeons also in an emergency setting is progressively substituting the old guard. It is worthwhile, too, that surgeons practicing in environments with less colorectal experience (< 50 colectomies performed yearly) more frequently prefer laparotomy (41%, 30/73) than those working in specialized centers (4%, 9/230).

Purulent peritonitis (Wasvary III) without visible perforation (Table 6)

The management of Wasvary III cases without visible perforation divides sourgeons’ opinion, as all answers, ranging from Hartmann operation to unprotected resection-anastomosis, received consideration. Almost one half opts for W&D (179, 44.4%), 152 proceed with resection-anastomosis (unprotected in 119 cases), and 69 prefer a Hartmann procedure, carried out laparoscopically in more than half of cases (39/69). Although with inconclusive results [20, 32], laparoscopic lavage/drainage is a low complexity procedure which has finally entered surgeons’ routine. Although recently discussed [33, 34] W&D is increasingly considered whenever the “hole” is not found at laparoscopy as it may be supposed that in the absence of a communication between colonic lumen and peritoneum, W&D may adequately manage a localized purulent peritonitis. Such a laparoscopy-oriented attitude both performing Hartmann resection and unprotected laparoscopic resection-anastomosis (almost half of the participants overall) in an emergency setting with an ongoing diffuse purulent peritonitis is surprising. Those operations seem complex and technically demanding procedures, potentially associated with significant morbidity, and needing resources not always available in any hospital in an emergency setting. This finding is not consistent with the average experience of survey participants, mostly new specialists or surgeons in training, whose rate of laparoscopic Hartmann procedures is double than that reported by more experienced colleagues. Possibly, personal experience in emergency colorectal surgery and may play a role in preferring an earlier conversion to laparotomy, with shorter operative time.

Pneumoperitoneum in clinically and hemodynamically stable patients (Table 6)

Traditionally considered a sign of severity and an indication for surgical exploration [10,11,12], isolated pneumoperitoneum at X-rays/CT-scan has lost its meaning, as evidenced by the wait-and-see attitude of 273 participants (about 2/3), whereas 28% preferred a laparoscopic exploration. Such a conservative attitude, which is more common among expert surgeons than young colleagues, is consistent with recent literature [35, 36].

Investigation at the umpteenth episode of mild DA in woman of childbearing age (Table 7)

CT is the answer for over 58%, followed by ultrasound in expert hands in 1/3 of the cases (34%). It is possible that the frequent lack of experience in performing AD ultrasound by the radiologist on call in an emergency setting, may eventually push the surgeon to try by objectify AD severity by CT-scan, despite the fertile age should probably lead to a more prudent approach.

Main indication to delayed elective colectomy (Table 8)

Participants are divided on the main indication to elective colectomy. In accordance with recent trends [22,23,24, 37], the impact on quality of life (135, 33.5%) and a previous complicated AD episode (106, 26.3%) prevail. Nevertheless, interestingly, the number of surgeons considering surgical resection with respect of the number of episodes, a concept that has been overtaken by literature, remains high (99, 24.6%). It is now almost abandoned, correctly, the (young) age of patients as an indication to sigmoidectomy, which is probably a legacy of the elective aggressive approach proposed during the 80s–90s, even after AD first episode, when the AD recurrence rate was believed to be substantially higher [38]. Significantly, the distribution of answers is not impacted by surgeon’s age and experience.

Percentage of Hartmann procedures among all emergency operations performed for AD in their environment (Table 9)

According to 259 participants (64%) the number of Hartmann operation is 25–50% of total emergency interventions for AD at their hospital, overall, with no significant differences associated with experience. This is surprising, considering that in US practice, Hartmann procedure is by far the preferred approach (93% out of all emergency operations for AD) [25]. Maybe, geographic differences, possibly associated with a more defensive approach by U.S. surgeons due to a higher impact of medical–legal issues, may explain such a surprising outcome.

Damage control surgery (colon resection without anastomosis, with/without laparostomy) (Table 9)

Although DCS has been proposed by international guidelines since the early 2010s [39] for the management of AD associated with systemic sepsis/hemodynamic instability, it is somewhat surprising that about 30% of participants does not consider it as an option in the case of severe, life-threatening cases, in their own environment. Not surprisingly, the result is statistically different among young and old surgeons with a percentage of surgeons having performed DCS more than double among esperts (colectomies performed: p = 0.0014; years of experience: p < 0.001).

Management of colo-vescical fistula (Table 10)

Colonic resection is the traditional approach to colo-vescical fistula, with or without protection stoma, and is preferred by about 2/3 of participants (262, 65%). A small percentage (50, 12%) consider an endoscopic approach in stable patients as allowed by the latest technological upgrades in fistula endoscopic management [40, 41], which that evidently has not yet entered clinical practice in most environments and remains a niche solution in expert hands. Significantly, a trend towards a higher rate of experienced surgeons preferring unprotected colon resection and lower rates of endoscopy-first attitude, seemingly reflects the impact of experience in such a challenging situation.

Surgical technique of delayed elective colon resection (Table 11)

According to over ¾ (311, 77.2%) of interviewees, delayed colon resection technique includes after AD includes a limited resection (sigmoidectomy rather than left colectomy), without main vessels (IMV and IMA) section at the origin, with the anastomosis at/under the sacral promontory as suggested by the current recommendations [24]. A systematic mobilization of splenic flexure is performed in almost 60% of cases, while, rather surprisingly, in most cases a colonic section is reported performed “proximally to colonic diverticula". Such ad attitude is not justified, also considering that diverticula often extend far beyond the sigmoid, not rarely reaching the transverse colon. Possibly, participants misunderstood the question and meant "to avoid diverticula" at the point of colon section/anastomosis.

Colorectal anastomosis integrity is almost unanimously checked by verifying the completeness of colon “rings” after circular stapling and by the hydro-pneumatic test. The Indocyanine Green test, a more recently introduced tool to check colonic and rectal stump vascularization at stapling [42, 43], is performed by more than half of participants, showing its recent and progressive spread in surgical practice.

Almost half of surgeons do not close the mesenteric breach in any way (stitches, clips, glue, etc.), which is a viable option according by recent recommendations [44, 45]. Following traditional teaching, roughly 80% of surgeons places a peri-anastomotic drainage, a practice that has recently undergone a critical review, especially if the patient is managed by ERAS (or Fast-Track) protoco [46].

“Young vs old” and limitations

One of the most ambitious objectives of the survey was to try to provide a differentiation in terms of experience by dividing the responders based on the number of colectomies performed (0–50 vs. > 50) and years of experience (≤ 5 vs. > 5). It is very difficult to define parameters that reflect "experience" and the impact this has on clinical practice. Although this appears to be a stretch and a simplification which may appear excessive given that expertise in colorectal surgery is not a measurable parameter but appears to be a close combination between experience and volume of activity, to our knowledge it seemed like an original effort that could better represent the current snapshot of what really happens in Italian hospitals. Despite expectations, different attitudes between the two experience groups were found only in the type of investigation to exclude colon cancer (difference found only in terms of number of colectomies), the size of the peritoneal abscess to be drained, the use of damage control surgery and in attitudes towards colovesical fistula. A relevant limitation could arise from the fact that the sample taken into consideration comes from the same country and that it is mainly composed of surgeons with little experience. An international survey, which mainly involves more experienced surgeons, and which also has feedback in terms of outcomes, could provide answers with a greater clinical impact. The analysis in the two study groups therefore highlighted minimal differences with very little clinical impact. In this sense, there is an important bias; it would be appropriate to be able to distinguish between responses influenced by real experience and those based exclusively on cultural knowledge of the current guidelines and recommendation and by becoming aware of this it might make more sense to consider the opinion of expert surgeons more.

Conclusions

The present survey represents an effort to define how AD management is evolving and how recent guidelines and recommendations have spread in surgeons’ practice.

Outpatient management of mild AD is slowly gaining acceptance, whereas small abscesses are largely considered not an indication for drainage until reaching 4–5-cm diameter, as suggested by guidelines.

A conservative management in clinically non-severe cases is spreading, as Wait and see policy is preferred by many in the case of extra-digestive air or non-radiologically drainable abscesses.

In more severe cases (Wasvary III), laparoscopy is largely preferred to laparotomy, as first (and often only) approach. A non-negligible number of surgeons, in particular young ones, seem confident in performing complex procedures in an emergency setting in presence of an ongoing diffuse peritonitis. Such a practice, which by the way is not contraindicated by guidelines, should probably induce some reflection. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is gaining acceptance in the management of life-threatening cases.

CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age, where other options should probably be preferred.

The attitude towards delayed, elective colectomy after AD is evolving, with a consistent number of surgeons considering quality of life and history of complicated AD the main indication for resection, consistently with guidelines recommendations.

Delayed elective colectomy for AD is mostly performed in a traditional fashion, avoiding the proximal ligation of main vessels, mostly mobilizing systematically the splenic flexure and performing a low anastomosis at/under the sacral promontory. ICG is spreading as a new tool to check anastomotic stumps’ vascularization.