Pivotal Clinical Trials on the Management of Diverticular Disease

Abstract The management of diverticular disease has undergone a major evolution over the past two decades, shifting away from episode-count triggers for surgery toward individualized strategies informed by patient-reported outcomes, recurrence risk, and high-quality randomized clinical trials. Pivotal decision analyses and randomized trials have reshaped the surgical treatment landscape, while parallel trials of antibiotic therapy have transformed the nonoperative management of uncomplicated disease. In this study, we provide a comprehensive synthesis of historical perspectives and modern evidence regarding the surgical and nonoperative management of diverticulitis, summarize key randomized trials across the disease spectrum, describe the evolution of operative techniques, and translate these findings into actionable guidance, including a patient-centered decision aid. A structured narrative review of pivotal trials, major guidelines, and multicenter randomized studies were performed, encompassing trials of antibiotic therapy for uncomplicated diverticulitis, laparoscopic lavage for perforated disease, operative strategy for complicated disease, elective resection versus conservative therapy for recurrent or persistent symptoms, and the evolution of minimally invasive and robotic surgical techniques. Trial design, eligibility, interventions, outcomes, and limitations were extracted and synthesized. The traditional “two-episode rule” has been supplanted by individualized, symptom- and quality of life (QoL)-driven decision-making. Routine antibiotic therapy for uncomplicated diverticulitis is not supported by randomized evidence and is now reserved for select patients. Laparoscopic lavage, initially promising for perforated diverticulitis, demonstrates variable outcomes and is now reserved for selected patients with Hinchey III disease; when resection is required, primary anastomosis with diverting ileostomy is increasingly favored over Hartmann's procedure because of markedly higher stoma reversal rates. Randomized trials of elective sigmoid resection show reduced recurrence and improved QoL for patients with persistent symptoms, though not universally across all patient groups, and minimally invasive-particularly robotic-surgical techniques continue to reduce perioperative morbidity. Contemporary management of diverticulitis requires individualized evaluation anchored in patient-reported outcomes, disease phenotype, comorbidity, and shared decision-making. This study synthesizes the current evidence and provides clinic-ready decision aid for patient discussions.