The role of non-operative management (NOM) in perforated diverticulitis: a systematic review

BACKGROUND: One of the most common and significant complication of acute diverticulitis is visceral perforation. Current clinical guidelines suggest conservative medical therapy can be adopted for selected patients with perforation, especially those with pericolic air, while its role remains less clear in cases of distant air. The aim of our study is to evaluate the role of non-operative management (NOM) in case of pericolic and distant air. MATERIALS AND METHODS: The authors conducted a comprehensive literature review; this search yielded 23 studies (17 retrospective, 5 prospective and 1 randomized control trial), including 2689 patients. RESULTS: Conservative management of patients with air in perforated diverticulitis was safe and feasible, with a overall pooled success rate of 90.2% (95% CI: 86.4-93). Specifically, among patients with pericolic extraluminal air, the success rate of NOM was 89.9%. In contrast, the role of NOM in cases with distant free air remains uncertain, with a lower success rate of only 27.8%. CONCLUSION: Non-operative management (NOM) appears safe and effective for patients with perforated diverticulitis and pericolic extraluminal air, provided there are no clinical signs of generalized peritonitis. In contrast, its role in cases with distant free air is highly uncertain: the pooled success rate is lower, even among hemodynamically stable patients. Based on these findings, early surgical management should be strongly considered for patients with distant free air, while NOM should only be attempted in highly selected cases under strict clinical and radiological monitoring. Conversely, NOM can be confidently recommended for patients with pericolic air who are stable and without diffuse peritonitis.