Abstract
The optimal management of localized diverticular perforation remains uncertain, with ongoing debate between surgical intervention and conservative antibiotic therapy. While randomized trials have addressed uncomplicated diverticulitis, evidence specific to perforated disease is limited and heterogeneous. This study aimed to evaluate the effectiveness of surgical intervention compared to antibiotic therapy in managing localized diverticular perforation in adults, focusing on key clinical outcomes including adverse events, stoma creation, mortality, and intra-abdominal abscess formation. We conducted a systematic review and meta-analysis of studies comparing surgical versus antibiotic therapy in adults with localized diverticular perforation. Major outcomes included composite adverse events, stoma creation, all-cause mortality, and intra-abdominal abscess. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I² statistic. Four comparative studies (n = 12,922 patients) were included. For composite adverse outcomes, no significant pooled difference was observed (Pooled OR 3.79, 95% CI 0.36-39.56, p = 0.266; I² = 97.4%), though individual studies showed conflicting results. Surgical intervention was associated with a significantly higher risk of stoma creation compared to antibiotics (Pooled OR 16.16, 95% CI 4.11-63.63, p < 0.001; I² = 43.3%). Mortality did not differ significantly between groups (Pooled OR 3.68, 95% CI 0.28-47.99, p = 0.320; I² = 88.8%). Intra-abdominal abscess rates were also comparable (Pooled OR 3.01, 95% CI 0.53-17.07, p = 0.212; I² = 87.8%). Surgical management of localized diverticular perforation provides definitive treatment but significantly increases the risk of stoma creation. Antibiotic therapy may be effective in carefully selected patients, particularly when initiated promptly, although study findings remain inconsistent. Given the high heterogeneity across available studies, further randomized trials are needed to establish evidence-based guidance for treatment selection in this patient population.