Int J Colorectal Dis (2012) 27:207–214 options for mild disease, associated abscesses, perforations, bleeding, and post-inflammatory complications are discussed separately. Also, the role of elective or preventive sigmoid resection will be addressed. Moderate cases of diverticular disease, such as phlegmon or small abscesses, can be treated conservatively. Initial prescrip- tions are often antibiotics and an easily digestible diet, although no clear evidence exists for both their beneficial actions. Preventive measures are thought to be more successful by several authors, high-fiber diet, and prevention of obesity and treatment of comorbidities are the usual ingredients [22–24]. Newer insights into the pathophysiology of diverticular disease, comparable to inflammatory bowel disease, have led to research on the potentials of 5-aminosalicylic acid (Mesalazine) and probiotics as adjunctive treatments for diverticular disease. Tursi et al. have described promising results, but these medications are still only administered in experimental settings [25, 26]. Large abscesses, if amendable and usually larger than 5 cm, should be good candidates for CT-guided percutaneous drainage [27]. This procedure may relieve symptoms or function as a bridge to (elective) surgery. A purulent or fecal peritonitis results from a perforation and is associated with high morbidity and mortality (10–35%) [28]. In these severe circumstances, acute surgical intervention is warranted. Hartmann’s procedure used to be the treatment of choice for decades, but in recent literature, a few interesting alternatives have emerged. Several authors consider a primary anastomosis a safe option in purulent peritonitis, with or without defunctioning stoma. Even in fecal perito- nitis, successful series of primary anastomosis have been published [29]. In 2008, Myers et al. introduced the concept of laparoscopic lavage for purulent peritonitis. This minimal invasive method provided resolution in 87% of patients and a reduction in mortality of up to 25% described for Hartmann’s procedure to 3% for laparoscopic lavage. Since then, several series have been published, but evidence from a randomized controlled trial is still to be awaited [30]. In order to prevent complicated disease after two episodes of acute diverticulitis, it has been considered good practice for years to perform elective sigmoid resection after two episodes of symptomatic diverticulitis and even doing so after one episode in the younger patients [31]. These recommendations drawn up by the American Society of Colorectal Surgeons in 2000 have recently been challenged. It is now thought that after a conservatively treated episode, diverticular disease usually follows a rather benign course and that complications occur mostly at first presentation [10, 32, 33]. Therefore, elective sigmoid resections should be restricted for use in treating complicated disease, such as symptomatic stenosis, fistulas to a hollow organ, or recurrent diverticular bleeding. Furthermore, recent publications on the natural course of diverticular disease suggest applying early 211 elective sigmoid resection in high-risk patients, such as the use of immune suppression therapy, having chronic renal failure, or collagen–vascular diseases. The management of diverticular disease in young patients remains controversial. A more hazardous course has been suggested. In contrast, opponents account the longer lifespan responsible for more recurrences and complications and thereby a higher cumu- lative risk of emergency surgery. An individual approach, weighing symptoms and peri-operative risks on a case by case basis, seems the most appropriate policy [34, 35]. Since the mid-1990s, laparoscopic sigmoid resections for diverticular disease have gained popularity. Several retrospec- tive series after laparoscopic sigmoid resections suggested improvements in minor complication rates, earlier resumption of food, and shorter hospital stay [36–38]. In January 2009, these beneficial effects were confirmed by a randomized controlled trial; the short-term results showed that a laparoscopic approach delivered a significant 15.4% reduc- tion in major morbidity, less pain, shorter hospitalization, and improved quality of life at the cost of a longer operating time [39]. After 6 months follow-up, the reduction in major morbidity accumulated to 27% [40]. Therefore, laparoscopic sigmoid resection may well be the procedure of choice for patients requiring elective resection for diverticular disease. Discussion and a proposal of a new classification This review of the current classification systems for a condition as complex as diverticular disease raises the question: Is there a need for another classification? We acknowledge that the introduction of still another classifica- tion could be even more confusing. Consequently, the aim of this review is not to add another modification or new classification, but to combine the existing classifications and make a comprehensive translation of the findings for use in daily clinical practice. By doing so, new imaging and treatment modalities are to be incorporated. The clinical applicability of this three-stage model has yet to be addressed by means of prospective data and expert panel validation. We propose three stages of differentiating diverticular disease: A—uncomplicated, B—chronic complicated, and C—acute complicated (see Table 6). We thereby address clinical findings (“Clinical presentation”), radiological find- ings (“Imaging”), and treatment modalities (“Treatment”) in different paragraphs. This stepwise approach resembles clinical decision making and forms the basis for a practice parameter on diverticular disease (see Table 6). The three stages A, B, and C is in accordance with the clinical classification as devised by Köhler et al. and the German Hansen/Stock classification. An important difference is that since indications for elective resection no longer depend on the number of episodes, there is no further need to distinguish