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Controversies in Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review

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Submitted:

04 July 2023

Posted:

05 July 2023

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Abstract
Background: This systematic umbrella review aims to investigate whether provide an analysis of guidelines regarding the treatment of diverticular abscesses summarizing the evidences from the best available practice. Material and methods: A systematic literature search was performed until using the Cochrane Overviews of Reviews model for search the ‘Clinical Practice Guidelines’; at the end of initial search only 12 guidelines, whose characteristics are reported in the following table were included in this analysis. The quality of the guidelines was assessed by adopting the 2017 updated version of the “Appraisal of Guidelines for Research and Evaluation II” (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. Conclusions: Currently, a lot of scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only, few guidelines, suggest the use of percutaneous drainage for abscess with a diameter greater than 4 cm .The difference among guidelines is the consequence of the different selection of scientific evidences. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
Keywords: 
Percutaneous drainage: Diverticular abscess
Subject: 
Medicine and Pharmacology  -   Surgery

1. Introduction

Guidelines are very important in daily clinical practice and are indeed the basis of surgical protocols. Their use – or misuse – has consequences not only in health-care. For instance, “clinical practice guidelines” (CPGs), have a dual role in malpractice litigation: defensive (exculpatory evidence) or accusatory (inculpatory evidence). In absence of evidence (“balance of probabilities” or “preponderance of evidence”), the claim is based only in the different opinions of experts).
In recent years, several guidelines on the treatment of acute complicated diverticulitis of the colon have been published by different scientific societies. Sometimes, however, the recommendations for the management of abdominal abscesses, in particular, are conflicting. This may be due to the different literature evidence used in the guidelines. Moreover, most of these evidence are low-level.
The goal of this review is to provide an analysis of guidelines regarding the treatment of diverticular abscesses [1] summarizing the evidences from the best available practice.

2. Materials and Methods

We use the Cochrane Overviews of Reviews model [1] for search the ‘Clinical Practice Guidelines’ in on PubMed, SCOPUS and on Web of Science, National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Guidelines International Network (GIN), Cochrane Library, PubMed, Embase, and American College of Chest Physicians (ACCP).
The following search strategy was carried out using the following keywords: “guideline”, “best practice”, “recommendations”, “consensus”, ”acute diverticulitis”, “acute colonic diverticulitis”, in various combinations with the Boolean operators and, or, and not.
The search for relevant studies was performed from January 2010 to April 2023. The checklist of PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was followed [2].
The PubMed function “related articles” was used to extend the search. We also performed hand-search of bibliography of included studies, to identify further potentially eligible investigations.
Inclusion criteria were all type of guidelines about the management of abdominal abscess from acute colonic diverticulitis. Language restriction was applied at only english language.
All studies were independently assessed for eligibility by two reviewers (RC and MM), and eventual controversies were resolved by a consensus among the reviewers.
The following data were independently extracted from included guidelines: first author name, scientific society promoted, country, year of publication, statement, consensus levels of agreement.
The quality of the guidelines was assessed by adopting the 2017 updated version of the “Appraisal of Guidelines for Research and Evaluation II” (AGREE II) [3]
A total of 23 items divided into 6 dimensions were analyzed for each guideline.
These 6 dimensions are as follows:
1. General objectives and areas of application
2. Involvement of stakeholders
3. Methodological rigor
4. Expository clarity
5. The applicability
6. Editorial independence
Each item was rated on a scale from 1 (strongly disagree) to 7 points (strongly agree). The score of each dimension is equal to the score of the various items contained in each dimension, calculated as a percentage according to the formula:
(Score achieved – lowest possible score)/ (Highest possible score – lowest possible score)X100
Based on the results obtained, a recommendation level A (strong recommendation) was assigned if all dimensions scored above 60%, or recommendation level B (weak recommendation) if at least one dimension scored below 60 %.

3. Results

At the end of initial search of titles and abstracts, 22 full text were screened for relevance; only 12 guidelines [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24], whose characteristics are reported in the following table (Table 1) were included in this analysis.
The remaining 10 guidelines were excluded for the following reasons:
The topic of guidelines is diverticular disease, but the Authors do not report the treatment of abscess (3 articles) [25,26,27].
The guidelines were not written in english language (5 articles) [28,29,30,31,32].
The guidelines were excluded for the analysis performed only on a subgroup of patients (2 articles) [33,34].
According to specific criteria: evalutation of guidelines’ quality with AGREE II instrument. [35].
According to the adopted criteria, seven guidelines reach a strong (Level A) recommendation (Kruis [5,6], Schultz [8], Sartelli [9], Hall [16], NICE [24], Francis [17], Cuomo [21]) (SDC 1) whereas five guidelines reach a weak (Level B) recommendation (Qaseem [4], Pietrzak [19], Binda [20], Andeweg [22], Andersen [23]) (SDC 2).
Focusing on quality of each of the 6 dimensions according to the adopted score:
  • Dimension 1 - General objectives and areas of application (item 1-3): all guidelines were high quality, totaling a percentage higher than 60% (SDC 3).
  • Dimension 2 - Involvement of stakeholders (item 4-6): most guidelines, except those of Binda [20] with 33.3% and Andeweg [22] with 44.4%, totaled a score above 60% (SDC 4).
  • Dimension 3 - Methodological rigor (item 7-14): all guidelines but that of Pietrzak(19) with 41.6%, scored higher than 60% (SDC 5)
  • Dimension 4 - Expository clarity by language, structure and format (item 18-21): all except one guideline (Qaseem with 45.8%)4 scored more than 60% (SDC 6).
  • Dimension 5 - the applicability by analyzing the possible barriers and factors facilitating the implementation of the guideline, the possible strategies to favor its adoption, the implication on the economic resources resulting from the application of the guideline (items 18-21); eight guidelines (Kruis [5,6], Schultz [8], Sartelli [9], Hall [16], NICE [24], Francis [17], Cuomo [21], Andeweg [22]) reached a high level of quality, totaling scores above 60% whereas the remainders (Qaseem [4], Pietrzak [19], Binda [20], Andersen [23]) achieved a weak level of recommendation, scoring below 60% (SDC 7).
  • Dimension 6 - Editorial independence (Items 22-23): most guidelines, except those of Pietrzak [19], Binda [20], Andeweg [22] and Andersen [23], achieved a good level of recommendation, scoring above 60% (SDC 8).
In the table we find the extended results of the evaluation (SDC 19).

3.1. Analysis of conflicting recommendations

The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage (Table 2).
A cut-off above which to perform percutaneous drainage was not defined in seven Guidelines, four of these Guidelines are previous versions of the ASCRS [12,13,14,15] and one is an earlier version of the EAES [18].
This diameter was standardized in four groups, in two of which there was an overlapping:
Less than 3 cm
between 3-4 cm
less than 4 cm
between 4-5 cm
Currently, most scientific societies (DGVS [5] and DGAV [6], ASCRS [16], ESCP [8], NICE [24], PSG and TChP [19]) recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics, only.
Differently, other guidelines, suggest the use of percutaneous drainage for abscess with a diameter greater than 4 cm (EAES and SAGES 2018) [17] and 5 cm (SICCR 2015) [20].
The difference among guidelines is the consequence of the different selection of scientific evidences.
The ESCP 2020 [36,37] recommendations, based on a systematic reviews and a multicentre study, suggest performing percutaneous drainage in abscesses larger than 3 cm in diameter [36,37].
ESCP 2020 [36,37] “Although the role of percutaneous drainage of abscesses in acute diverticulitis is not completely clear, it may be considered in patients with an abscess larger than 3 cm. Emergency surgery should be kept as last resort for patients failing other nonsurgical treatments”
Also the LG DGVS/DGAV 2022 supports this recommendation [29,38]:
DGVS and DGAV 2022 [38,39] “To distinguish between micro and macro abscesses, a threshold value of approximately 3 cm can be applied, since this reflects the possibility of interventional drainage and the risk of recurrence correlates with the size of the abscess”
“Larger retroperitoneal or paracolic abscesses (> 3cm) can be interventionally drained (sonography, CT)”
This opinion is also the one reported in the ASCRS 2020 Guidelines, which are based on two prospective studies [38,39].
ASCRS 2020 [38,39] “Image-guided percutaneous drainage is usually recommended for stable patients with abscesses >3 cm in size”
“Evidence level moderate-quality evidence 1B, recommendation grade: strong recommendation”
Finally, we should highlight that even the NICE guidelines, based on 5 studies, suggest performing percutaneous drainage in abscesses with a diameter > 3 cm.
NICE 2019 [40,41,42,43,44] “The committee agreed that if percutaneous drainage is an anatomically feasible option this could be considered alongside a discussion with the patient about the risks and benefits of surgery. In people with a CT-confirmed diverticular abscess, re-imaging may be considered if the condition does not improve clinically or if there is deterioration.”
Currently only the guidelines of the EAES and SEGES 2018 [17] suggest percutaneous drainage in abscess with a diameter greater than 4 cm.
In identifying the abscess’ diameter, these guidelines are largely based on systematic reviewes by Gregersen and on another study [45,46,47].
In conclusion only WSES 2020, based on 5 studies, reported a major cut-off of 4-5 cm as lower abscess diameter for percutaneous drainage [48,49,50,51,52].
WSES 2020 [48,49,50,51,52] “For patients with a small (< 4–5 cm) diverticular abscess, we suggest an initial trial of non-operative treatment with antibiotics alone (weak recommendation based on low-quality evidence, 2C).We suggest to treat patients with large abscesses with percutaneous drainage combined with antibiotic treatment; whenever percutaneous drainage of the abscess is not feasible or not available, we suggest to initially treat patients with large abscesses with antibiotic therapy alone, clinical conditions permitting. Alternatively, an operative intervention is required”

3.2. Historical view

Most of the previous guidelines suggested the possibility of performing percutaneous drainage but did not define the dimensions of the abscess that could be drained and sometimes also the advantages.
Previous guidelines ASCRS 2006 (based on one study), ASCRS 2000 (based on expert opinion) and ASCRS 1995 (based on expert opinion) suggested performing percutaneous drainage in large diverticular abscesses but did not identify reference diameters [53].
ASCRS 2006 [53] “Radiologically guided percutaneous drainage is usually the most appropriate treatment for patients with a large diverticular abscess.”
ASCRS 2000 [53] “For a patient with a large diverticular abscess, two options are available, percutaneous or surgical drainage. The potential advantage of percutaneous drainage is that it may allow stabilization of the patient and avoidance of a temporary stoma and a second operation. Drainage of radiologically accessible unilocular collections may allow temporary defervescence before resection with primary anastomosis.”
ASCRS 1995 [53] “For a patient with a large diverticular abscess that does not resolve with medical treatment two options are available, percutaneous or surgical drainage. The potential advantage of percutaneous drainage is stabilization of the patient and avoidance of a temporary stoma. Unilocular collections with a radiologic "window" for drainage allow temporary palliation before resection with primary anastomosis.”
In the EAES 2009 [54] guidelines, based on one study, and then in the DKS 2012 [55,56,57] guidelines, based on 4 studies, percutaneous drainage was generically suggested for both mesenteric and pelvic abscesses
EAES 2009 [55,56,57] “Hinchey I (abscess confined to mesentery) should first be treated by percutaneous drainage where possible, followed by sigmoid colectomy and primary anastomosis in fit patients (consensus)”.
“Hinchey II (pelvic abscess, whatever the localization) should also be treated by percutaneous drainage, and followed later by sigmoid resection in most cases, but the risk in patients with comorbidity must be considered in the final decision (consensus)”.
Guidelines PSG/TChP 2015, based on two studies, recommend percutaneous drainage in abscesses with a minimum diameter of 3 cm [58,59,60].
PSG andTChP 2015 [58,59,60] “Abscesses < 3 cm may be treated with antibiotics only, provided that the patient is continuously monitored. If technically feasible, abscesses > 3 cm should be treated with antibiotics and USG/CT-guided percutaneous drainage.”
On the other hand, the ASCRS 2014 guidelines, based on 4 studies, suggested performing percutaneous drainage in abscesses with a minimum diameter between 3-4 cm [61,62,63,64].
ASCRS 2014 [61,62,63,64] “Deciding which patients with diverticular abscesses require percutaneous drainage rather than medical management, and which patients should undergo definitive surgery after successful abscess treatment (with or without percutaneous drainage), remains controversial. Several studies support medical treatment without percutaneous drainage for clinically stable patients with small abscesses up to 3 to 4 cm in the largest dimension, recognizing that many of these abscesses will resolve without a drainage procedure. However, patients who do not clinically improve without drainage should undergo percutaneous drain placement”.
In the past, the previous guidelines of the DGVS and DGAV 2014, based on five studies, indicated percutaneous drainage only in abscesses with a diameter > 4 cm [65,66,67,68,69].
DGVS and DGAV 2014 [65,66,67,68,69] “Retroperitoneal or paracolic abscesses can be drained interventionally (US, CT). In the case of small abscesses that cannot be punctured safely, conservative treatment alone should be undertaken with daily monitoring of clinical symptoms and inflammation parameters (CRP, leukocytes). Strong consensus; recommendation”
Even the not recent Italian guidelines produced by SICCR (based on 3 studies) [70,71,72], GRIMAD [73,74,75] (based on 3 studies) and international guidelines produced by WSES [76,77,78] (based on 3 studies) suggest performing percutaneous drainage in case of abscesses with a diameter > 4 cm.
SICCR 2015 [70,71,72] “What are the treatment options for diverticular abscess? We recommend the guided percutaneous drainage combined with antibiotics as the preferable treatment for >4 cm diverticular abscesses. Those abscesses not responding to or not amenable to non-operative management should be treated surgically”
GRIMAD 2014 [73,74,75] “The best treatment option for a diverticular abscess >4 cm in diameter is percutaneous guided drainage. Diverticular abscesses not responding, or not amenable, to non-operative management should be treated surgically.”
WSES 2011 [76,77,78] “Systemic antibiotic treatment alone is usually the most appropriate treatment for patients with a small (<4 cm in diameter) diverticular abscess and image guided percutaneous drainage is for those with a large (>4 cm in diameter)”
Previously the WSES [79,80,81,82,83] based on five studies, and NTVG [84,85,86,87,88], based on five studies, reported the recommendation of the cut-off of 4-5 cm as lower abscess diameter for percutaneous diameter.
WSES 2016 [79,80,81,82,83] “Patients with large abscesses (>4–5 cm) can best be treated by percutaneous drainage combined with antibiotic treatment.”
NTVG 2013 [84,85,86,87,88] “Smaller abscesses (<4–5 cm) can be treated with antibiotics alone, whereas larger abscesses can best be treated with percutaneous drainage combined with antibiotic treatment (level 3).”

3.3. Analysis of the degree of overlap in the studies on which the guidelines are based

To determine overlap between guidelines, ‘citation matrices’ were generated (Table 3). In the WSES guidelines (60%) there is the greatest overlap of the studies included, followed by those of ASCRS 2020 (50%) and EAES/SAGES 2018 50% compared to the other guidelines (NICE 2019 33.3%, DVGS/DGAV 2022 0%).
DGVS and DGAV 2022 WSES 2020 ESCP 2020 ASCRS 2020 NICE 2019 EAES and SAGES 2018
Gregersen 2018 X
Lambrichts 2019 X
Buchwald 2017 X
Gregersen 2016 X X
Lamb 2014 X
Subhas 2014 X
Singh 2008 X
Siewert 2006 X X
Brandt 2006 X X X
Kumar 2006 X X
Ambrosetti 2006 X
Kaiser 2005 X
Elagili 2005 X
Total 0/1 3/5$$(60%) 0/2 1/2$$(50%) 2/6$$(33.3%) 1/2$$(50%)
Some guidelines (DVGS/DGAV 2022, NICE 2019 and EAES/SAGES 2018) contained systematic reviews, so we performed a subsequent analysis of the degree of overlap of the studies on which the included systematic reviews were based (Table 4).
Fowler 2021 Lee 2020 Gregersen 2016 Lamb 2014
Aquina 2019 X X
Lambrichts 2017 X X
Gregersen 2018 X
You 2018 X X
Buchwald 2017 X
Jalouta 2017 X X
Titos-Garcia 2017 X
Gregersen 2016
Devaraj 2016 X
Garfinkle 2016 X X
Occhionorelli 2016 X
Rose 2015 X
Elagili 2015 X X
Trenti 2015 X X X
Subhas 2014 X X X
Sallinen 2014 X X
Li 2014 X
Edna 2014 X
Elagili 2014 X X X
Pappalardo 2013 X X
Felder 2013 X X X X
Gaetner 2013 X X X X
Van Der Wall 2013 X X X X
Ambrosetti 2012 X
Levack 2012 X
Hall 2011 X
Dharmarajan 2011 X X X X
Park 2010 X
Etzioni 2010 X X
Eglinton 2010 X X
Nelson 2008 X
Singh 2008 X X X X
Pautrat 2007 X X X
Alvarez 2007 X X X
Siewert 2006 X X X
Kumar 2006 X X
Brandt 2006 X X X X
Durmishi 2006 X X
Kaiser 2005 X X X
Ambrosetti 2005 X X X X
Broderick-Villa 2005 X
Macias 2004 X X X X
Poletti 2007 X X
Harisinghani 2003 X X
Bahadursingh 2003 X X X
Ambrosetti 2002 X
Bernini 1997 X
Sher 1997 X
Belmonte 1996 X
Schechter 1994 X X
Tudor 1994 X
Detry 1992 X X
Lambiase 1992 X X
Hachigian 1992 X X X
Ambrosetti 1992 X
Smirniotis 1991 X
Stabile 1990 X X X
Mueller 1987 X X
Neff 1987 X X
Saini 1986 X X
Auguste 1985 X
Alexander 1983 X
Total 20/41
(48.71%)		 22/23
(95,65%)		 22/42
(53.38%)		 15/22
(68.1%)
The two systematic reviews (Gregersen and Lamb) included in the guidelines were the first to be published (2016 - 2014) and included 42 and 22 studies respectively; Gregersen's review had a study overlap of 53.65%, while Lamb's had a greater overlap (68.1%). The two most recent systematic reviews did not include a number of higher studies (41 in Fowler 2021, 22 in Lee 2020), but in Lee's rate of overlap of studies was higher than in previous ones. From this it follows that the guidelines that contained the two systematic reviews (NICE, EAES and SAGES, DVGS/DGAV) are based on a higher overlap rate of the studies included.

4. Discussion

The current management of diverticular abscesses requires a multidisciplinary approach involving infectious disease specialists, interventional radiologists and surgeons.
The therapeutic decisions are based on CT scan results, which provide accurate information about the size and location of the abscesses and help determine the appropriate treatment approach.
For small sized diverticular abscesses, intravenous antibiotic therapy is recommended. On the other hand, larger abscess may require percutaneous drainage if anatomically accessible.
Surgery is reserved for cases where percutaneous drainage fails or for large abscesses that cannot be accessed through percutaneous drainage and are unresponsive to antibiotic therapy.
However, there is controversy among different guidelines regarding the cut-off diameter for abscesses that require percutaneous drainage. In fact the definition of “'small” and “large” abscesses varies among the guidelines, leading to inconsistent recommendations [89].
For example, one of the most recent guidelines, from the German Societies for Gastroenterology and Visceral Surgery (DGVS/DGAV), identifies a diameter of 3 cm as the value for distinguishing between micro and macro abscesses [94]. This cut-off is also shared by other societies, such as the ASCRS (American Society of Colon and Rectal Surgeons) [95] and NICE (National Institute for Health and Care Excellence) [96]. However, differing from these is the World Society of Emergency Surgery (WSES), which reported a cut-off of 4-5 cm [97].
Some studies, including one by Lambrichts, have shown worse outcomes for patients who for patients who underwent percutaneous drainage compared to those who received medical therapy alone. These results may be influenced by selection bias, as patients in worse general conditions are more likely to be enrolled in the percutaneous drainage [90,91].
Another study conducted by Elagili et al. sought to evaluate the difference between treatment with antibiotic therapy alone and percutaneous drainage in abscesses of diameter larger than 3cm. This showed that selected patients could be treated initially with antibiotics alone without any negative consequences on their outcomes [99].
However, a retrospective analysis conducted by Buchwald et al. on patients admitted to Christchurch Hospital evaluated the long-term outcomes of conservative treatment in diverticular abscesses (Hinchey I and II). It was found that the number of recurrences was higher in patients who were treated with initial conservative treatment (antibiotics +/- percutaneous drainage) than in those who underwent surgery [100].
The NICE guidelines suggest considering percutaneous drainage only for abscesses larger than 3 cm due to technical difficulties in performing the procedure on smaller abscesses [92].
However, these guidelines acknowledge that the evidence supporting this recommendation is of very low quality due to selection bias and other limitations.
Meta-analyses reported by NICE have evaluated outcomes without stratifying patients based on different abscess diameters [41,44] Therefore, there is a need for new large studies to determine the appropriate diameter cutoff for percutaneous drainage.

5. Conclusion

The treatment of abdominal abscesses in patients with acute colonic diverticulitis is a significant therapeutic challenge. The approach has shifted from surgical intervention to non-surgical, minimally invasive management over the years. This change is attributed to advancements in technology, improved intensive care monitoring, the use of computed axial tomography, and the introduction of minimally invasive techniques such as percutaneous eco/CT-guided drainage.
Various national and international societies have attempted to provide treatment recommendations, but there are conflicting opinions, especially regarding the abscess cutoff diameter for intervention. Guidelines often have a low degree of recommendation due to the low quality of evidence, primarily stemming from selection bias and imprecision.
Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. Generally, small abscesses are recommended for medical antibiotic therapy, while larger abscesses may require percutaneous drainage, with or without antibiotic therapy.
In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
This pursuit will undoubtedly result in more accurate and shared recommendations, which can resolve the controversies in various guidelines. Most importantly, it can lead to improved treatment outcomes for patients with abdominal abscess from acute colonic diverticulitis.

Author Contributions

All authors substantially contributed to the manuscript. All authors read and approved the final version of the manuscript.

Funding

No funding was received for the present study.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
For this clinical case, no ethics commission has met.

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Table 1. Guidelines included.
Table 1. Guidelines included.
Guideline Data of publication Previous editions Authors
American
College of Physicians		 ACP 2022 (Qaseem4) Standards committee
German Societies for Gastroenterology and Visceral Surgery DGVS
DGAV		 2022
(Kruis 5,6)		 2014 (Kruis 7) Expert panel
European Society of Coloproctology ESCP 2020 (Schultz8) Consensus meeting
World Society of Emergency Surgery WSES 2020 (Sartelli9) 2016 (Sartelli 10), 2011 (Sartelli11) Expert panel
American Society of Colon and Rectal Surgeons ASCRS 2020 (Hall16) 2014 (Feingold15), 2006 (Rafferty14), 2000 (Wong13), 1995 (Roberts12) Standards committee
The National Institute for Health and Care Excellence NICE 2019 (NICE24) Standards committee
Gastrointestinal and Endoscopic Surgeons SAGES 2018
(Francis17)		 Consensus meeting
European Association for Endoscopic Surgery EAES 2009 (Köhler18) Consensus meeting
Polish Society of Gastroenterology and the Association of Polish Surgeons PSG
TChP		 2015 (Pietrzak19) Expert panel
Italian Society of Colon and Rectal Surgery SICCR 2015 (Binda20) Expert panel
Italian Study Group of Diverticular Disease GRIMAD 2014 (Cuomo21) Consensus meeting
Netherlands Society of Surgery NTVG 2013 (Andeweg22) Expert panel
Danish Surgical Society DKS 2012 (Andersen23) Expert panel
Table 2. Lower diameter of abscess in patients underwent percutaneous drainage.
Table 2. Lower diameter of abscess in patients underwent percutaneous drainage.
Not reported a diameter Diverticular abdominal abscess (diameter > 3 cm) Diverticular abdominal abscess (diameter > 3-4 cm) Diverticular abdominal abscess (diameter > 4 cm) Diverticular abdominal abscess (diameter > 4-5 cm)
DKS 2012 (Andersen23)
EAES 2009 (Köhler18)
ASCRS 2006 (Rafferty14)
ASCRS 2000 (Wong13)
ASCRS 1995 (Roberts12)		 DGVS and DGAV 2022 (Kruis5,6)
ASCRS 2020 (Hall16)
ESCP 2020 (Schultz8)
NICE 2019
(NICE24)
PSG and
TChP 2015 (Pietrzak19)		 ASCRS 2014 (Feingold15) EAES and SAGES 2018 (Francis17)
SICCR 2015 (Binda20)
GRIMAD 2014 (Cuomo21)
WSES 2011 (Sartelli11)
DGVS and DGAV 2014 (Kruis7)		 WSES 2020 (Sartelli9)
WSES 2016 (Sartelli10)
NTVG 2013 (Andeweg22)
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