Primary Anastomosis without Diversion in Perforated Diverticulitis: Is it Safe?

Diverticular disease, particularly perforated diverticulitis (PD), is a growing global health concern, with its management traditionally involving non-restorative resections, which significantly impact patients' quality of life. More recently, there has been a paradigm shift toward performing primary anastomosis without diversion (PAWOD) for these patients. This review aims to evaluate and discuss the safety and practicality of PAWOD in acute PD, a topic that remains controversial. Various surgical options based on the location of the disease and patient stability have been explored, including considerations for pan-diverticular disease. We highlight the factors favoring PAWOD while also acknowledging the continued relevance of protective stomas and non-restorative surgery. The review delves into technical considerations, including the role of minimally invasive surgery, innovative surgical techniques, and adjuncts to reduce anastomotic leaks. While PAWOD is a safe and increasingly feasible option for appropriately selected patients, its widespread adoption still faces practical challenges, including surgeon expertise and institutional resources. With ongoing advancements and dedicated training, the criteria for PAWOD are likely to broaden, ultimately enhancing patient outcomes in emergency surgery for PD.