Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis:: A case-control study

Purpose: CT-scan-guided percutaneous abscess drainage of Hinchey Stage H diverticulitis is considered the best initial approach to treat conservatively the abscess and to subsequently perform an elective sigmoidectomy. However, drainage is not always technically feasible, may expose the patient to additional morbidity, and has not been critically evaluated in this indication. This study was undertaken to compare the results of percutaneous drainage vs. antibiotic therapy alone in patients with Hinchey 11 diverticulitis. Methods: This was a case-control study of all patients who presented in our institution with Hinchey Stage 11 diverticulitis between 1993 and 2005. Thirty-four patients underwent abscess drainage under CT-scan guidance (Group 1), and 32 patients were treated with antibiotic therapy alone (Group 2), in most cases because CT-scan-guided abscess drainage was considered technically unfeasible by the interventional radiology team. Initial conservative treatment was considered a failure when: 1) emergency surgery had to be performed, 2) signs of worsening sepsis developed, and 3) abscess recurred within four weeks of drainage. Results: The median size of abscess was 6 (range, 3-18) cm in Group 1 and 4 (range, 3-10) cm in Group 2 (P=0.002). Median duration of drainage was 8 (range, 1-18) days. Conservative treatment failed in 11 patients (33 percent) of Group 1, and in 6 patients (19 percent) of Group 2 (P=0.26). Ten patients (29 percent) in Group 1 and five patients (16 percent) in Group 2 underwent emergency surgery (P=0.24); there were four postoperative deaths (26.6 percent) in this subgroup. Twelve patients (35 percent) in Group I and 16 patients (50 percent) in Group 2 subsequently underwent an elective sigmoid resection (P=0.31). In this subgroup of patients, there was neither anastomotic leakage nor postoperative death. Conclusions: Emergency surgery for Hinchey Stage 11 diverticulitis carries a high mortality rate and should be avoided. To achieve this, antibiotic therapy alone seems to be a safe alternative, whenever percutaneous drainage is technically difficult or hazardous. Actually, our data did not demonstrate any benefit of CT scan-guided percutaneous abscess drainage, suggesting that the role of interventional radiology techniques in this indication deserves further critical evaluation.