disease, Thorson and Goldberg described the disease based on the type of presentation, timing and duration of the disease, and complexity.10 Table 24.3 Acute Uncomplicated Diverticulitis
Trang 1improved outcomes in colon and rectal surgery
23 Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B
Long-term results and functional outcome after Ripstein
rectopexy Dis Colon Rectum 2000; 43(1): 35–43
24 Winde G, Reers B, Nottberg H et al Clinical and functional results
of abdominal rectopexy with absorbable mesh-graft for treatment
of complete rectal prolapse Eur J Surg 1993; 159(5): 301–5
25 Novell JR, Osborne MJ, Winslet MC, Lewis AA Prospective
randomized trial of Ivalon sponge versus sutured rectopexy for
full-thickness rectal prolapse Br J Surg 1994; 81(6): 904–6
26 Mann CV, Hoffman C Complete rectal prolapse: the
ana-tomical and functional results of treatment by an extended
abdominal rectopexy Br J Surg 1988; 75(1): 34–7
27 Aitola PT, Hiltunen KM, Matikainen MJ Functional results
of operative treatment of rectal prolapse over an 11-year
period: emphasis on transabdominal approach Dis Colon
Rectum 1999; 42(5): 655–60
28 Allen-Mersh TG, Turner MJ, Mann CV Effect of abdominal
Ivalon rectopexy on bowel habit and rectal wall Dis Colon
Rectum 1990; 33(7): 550–3
29 Watts JD, Rothenberger DA, Buls JG, Goldberg SM,
Nivatvongs S The management of procidentia 30 years’
experience Dis Colon Rectum 1985; 28(2): 96–102
30 Huber FT, Stein H, Siewert JR Functional results after
treat-ment of rectal prolapse with rectopexy and sigmoid
resec-tion World J Surg 1995; 19(1): 138–43
31 Husa A, Sainio P, von Smitten K Abdominal rectopexy and
sigmoid resection (Frykman-Goldberg operation) for rectal
prolapse Acta Chir Scand 1988; 154(3): 221–4
32 Duepree HJ, Senagore AJ, Delaney CP, Fazio VW Does means
of access affect the incidence of small bowel obstruction and
ventral hernia after bowel resection? Laparoscopy versus
laparotomy J Am Coll Surg 2003; 197(2): 177–81
33 Solomon MJ, Young CJ, Eyers AA, Roberts RA Randomized
clinical trial of laparoscopic versus open abdominal rectopexy
for rectal prolapse Br J Surg 2002; 89(1): 35–9
34 Purkayastha S, Tekkis P, Athanasiou T et al A comparison of
open vs laparoscopic abdominal rectopexy for full-thickness
rectal prolapse: a meta-analysis Dis Colon Rectum 2005;
48(10): 1930–40
35 Zittel TT, Manncke K, Haug S et al Functional results after laparoscopic rectopexy for rectal prolapse J Gastrointest Surg 2000; 4(6): 632–41
36 Himpens J, Cadiere GB, Bruyns J, Vertruyen M Laparoscopic rectopexy according to Wells Surg Endosc 1999; 13(2): 139–41
37 Dulucq JL, Wintringer P, Mahajna A Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse A prospective study Surg Endosc 2007; 21(12): 2226–30
38 Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JR Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse Dis Colon Rectum 2000; 43(5): 638–43
39 Kessler H, Jerby BL, Milsom JW Successful treatment of rectal prolapse by laparoscopic suture rectopexy Surg Endosc 1999; 13(9): 858–61
40 Bruch HP, Herold A, Schiedeck T, Schwandner O Laparoscopic surgery for rectal prolapse and outlet obstruction Dis Colon Rectum 1999; 42(9): 1189–94
41 Kellokumpu IH, Vironen J, Scheinin T Laparoscopic repair
of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function Surg Endosc 2000; 14(7): 634–40
42 Baker R, Senagore AJ, Luchtefeld MA Laparoscopic-assisted
vs open resection Rectopexy offers excellent results Dis Colon Rectum 1995; 38(2): 199–201
43 Benoist S, Taffinder N, Gould S, Chang A, Darzi A Functional results two years after laparoscopic rectopexy Am J Surg 2001; 182(2): 168–73
44 Kairaluoma MV, Viljakka MT, Kellokumpu IH Open vs lap-aroscopic surgery for rectal prolapse: a case-controlled study assessing short-term outcome Dis Colon Rectum 2003; 46(3): 353–60
45 Steele SR, Goetz LH, Minami S et al Management of recur-rent rectal prolapse: surgical approach influences outcome Dis Colon Rectum 2006; 49(4): 440–5
46 Pikarsky AJ, Joo JS, Wexner SD et al Recurrent rectal pro-Recurrent rectal pro-lapse: what is the next good option? Dis Colon Rectum 2000; 43(9): 1273–6
Trang 224 Operative and nonoperative therapy for diverticular disease
R Scott Nelson and Alan G Thorson
Unlike other diseases in this text diverticular disease is a common
problem with multiple presentations
Challenging Case #1
A 52-year-old male presents to the Emergency Department
with complaints of left lower quadrant (LLQ) abdominal pain
for the last 16 hours The patient describes the pain as
esca-lating in nature, unrelieved with a bowel movement History is
unremarkable except for hypertension, which is treated with a
beta-blocker The patient denies any similar symptoms
previ-ously Abdominal exam reveals a mildly distended abdomen,
with tenderness to the left lower quadrant, but no guarding or
rigidity A basic metabolic profile is normal and complete blood
count reveals a leukocytosis at 14,000 CT scan of the abdomen
and pelvis with oral and rectal contrast demonstrates
thicken-ing of the sigmoid colon with mesenteric thickenthicken-ing but no
identifiable abscess or perforation
Case ManageMenT
In a 52-year-old male patient with the aforementioned findings, a
clinical and radiographic diagnosis of acute uncomplicated
diver-ticulitis is confirmed Treatment should consist of broad spectrum
antibiotics, typically, Ciprofloxacin and Flagyl, IV fluids, and bowel
rest Admission to the hospital is based on physical examination,
comorbidities, and CT findings Treatment should be continued
until the patient’s pain has resolved or symptomatic improvement
is noted, and then oral intake may resume Antibiotics are typically
continued for 7–10 days following resolution of pain
Challenging Case #2
A 67-year-old female presents to the ED with a two day history
of escalating LLQ pain and evidence of diverticulosis on
colonos-copy 10 years ago Physical exam reveals a tender LLQ without
peritoneal signs, and fullness to palpation WBC count is elevated
at 17,000 and a CT scan shows a thickened inflamed sigmoid
colon with a 3 cm abscess on the medial aspect of the colon
Case #2 Management
Any patient diagnosed with a diverticular abscess, elevated WBC
count, and pain, should be admitted to the hospital and started on
intravenous fluids and antibiotics The risk of requiring an
emer-gent operation secondary to failure of conservative management is
0–30% Patients with an abscess >2–3 cm should also be evaluated
for percutaneous drainage Following these measures the patient
should be followed to assess clinical improvement Resolution
based on physical exam and bowel activity can dictate further
conservative treatment Elective surgery should be scheduled in
the near future based on the patient’s overall health and ability to
undergo an operation Failure of conservative therapy deems that
an operation be completed during that hospitalization
Challenging Case # 3
65-year-old male admitted for acute uncomplicated diverticu-lar disease is started on antibiotic therapy After 3 days of I.V antibiotic therapy and IV fluid the patient’s pain resolves He is switched over to oral antibiotics and started on a low residue diet The patient describes the same pain, increasing in the LLQ over the next 24 hours He is once again made NPO and I.V antibiot-ics are restarted This time, attempts to switch the patient to oral antibiotics are successful and he is discharged home However 10 days later he returns with LLQ pain again and CT scan continues
to show uncomplicated diverticulitis He is restarted on oral anti-biotics and his pain resolves
Case #3 Management
Chronic diverticulitis should be treated with an operation There are not many studies in the literature dedicated to just chronic diverticular disease; however, it is a subject that probably does not need such study Patients with pain that is clearly attribut-able to a surgical disease and that persists despite maximal medi-cal therapy are candidates for an operation and should have the problem dealt with
Challenging Case #4
A 72-year-old female presents to her primary care physician for the 4th time in 6 months with a urinary tract infection (UTI) The patient has no known history of abdominal pain, and no previous history of frequent UTI, and now has noticed pneumaturia The
culture shows multiple organisms, including E Coli The last
pre-vious colonoscopy 2 years ago demonstrated diverticula, but was otherwise normal Abdominal exam reveals no abnormal find-ings What would be the best way to proceed in the diagnosis and treatment of this individual?
Case #4 Management
This patient should undergo confirmatory testing and CT scan If the diagnosis is unsuccessful with barium enema, cystoscopy can also be attempted If the patient is a candidate for surgery and the suspicion remains without confirmation, operative treatment is indicated Laparoscopic resection has been shown to be possible
in these types of cases as well
Challenging Case #5
A 34-year-old female 2 weeks after a renal transplant for poly-cystic kidney disease complains of anorexia and vague abdomi-nal tenderness, more on the left side Bowel movements which had been normal have now stopped over the last three days
A palpable kidney in the LLQ is not overly tender, and renal function does not seem abnormal for the time since opera-tion No changes have been made in her immunosuppressive medication
Trang 3improved outcomes in colon and rectal surgery
Case #5 Management
Prophylactic colectomy for diverticulosis is not recommended
before transplant However, the incidence of diverticulitis
follow-ing transplant is higher than the general population, though still
relatively rare in the transplant population overall Additionally
patients receiving immunosuppressive therapy are at a higher
risk for complicated diverticulitis and, more importantly, delay
in diagnosis significantly increases their morbidity and
mortal-ity Patients with polycystic kidney disease also show higher rates
of diverticulosis and diverticulitis as opposed to other
popula-tions These patients require aggressive diagnostic evaluation
with CT scan and if diverticulitis is confirmed, aggressive surgical
management
inCidenCe Of diverTiCulOsis and diverTiCuliTis
It is estimated that nearly 30% of the U.S population will have
evi-dence of diverticulosis by age 60 That number increases to 60%
by the time an individual reaches 80 years of age (1) However,
of these patients, only 10–25% will develop symptomatic
diver-ticulitis and of those who become symptomatic only 10–20%
of individuals will require hospitalization Of patients who are
hospitalized with symptomatic disease, 20–50% will require an
operation (2) Overall, <1% of patients with diverticula will
ulti-mately require surgical management In recent years there has
been a shift in the treatment of patients with diverticulitis as
more are treated as outpatients with oral antibiotics than with
hospitalization (2) Left sided diverticula predominant among
the more western countries including the United States, Canada,
United Kingdom, Europe and Brazil While left-sided disease is
still more common, right-sided disease is associated more with
eastern countries such as Japan, China, Korea, and Singapore.(3)
The male to female ratio appears to be about equal
ClassifiCaTiOn
In order to determine how best to treat patients presenting with
diverticular disease, classification of the severity of the disease
is necessary Diagnostic modalities have changed substantially
within the last 40 years and along with it our paradigms of
treat-ment Park, in the late 60s and early 70s along with fellow
con-temporaries including Larson, and Haglund (4–6) attempted to
evaluate the natural history of diverticulitis in order to classify the
severity of disease Many of the guidelines and recommendations
by various societies for the treatment of diverticulitis are based
on this original work However, their diagnosis of the disease was
based on barium enema, physical examination, and pathology
reports While all three methods are sufficient to make a
diagno-sis, the improved sensitivity and specificity of newer technology
has changed the way we diagnosis, classify and treat this disease
today In recent years, criteria for the classification of diverticulitis
has changed from findings on barium enema, history and
physi-cal examination and colonoscopy to findings based on computed
tomography (CT) scanning These scans now provide practical
and predictive information that assist in the classification and
severity of the disease process A number of useful classification
systems have been developed to assist the physician in deciding
on a course of treatment.(1, 7, 8) These classification systems can
be based on CT scans findings (Table 24.1 and Figures 24.1, 24.2
and 24.3), intraoperative findings (Table 24.2), or a more global view of the disease (Table 24.3)
Ambrosetti has done extensive work on CT findings of diver-ticular disease and developed a classification system based on the appearance of the inflamed colon (7) His work is simple and divides patients into two groups; uncomplicated or complicated (Table 24.1) Other studies have looked at the size of the abscess and amount of mesenteric air to determine if those are predictors
of failure of nonoperative therapy.(8) Another useful method of evaluating diverticulitis was reported
in 1978 by Hinchey This is based on findings at the time of sur-gery and the decision for determining the correct surgical inter-vention was based on this classification system.(9) This simple formula divided the intraoperative findings into four categories based on the amount and type of peritonitis (Table 24.2) However not all diverticular disease can be classified by CT scan or at the time of an operation In a recent description of the
Table 24.1 Ambrosetti classification of diverticulitis based on CT
findings
ambrosetti CT Classifications
Uncomplicated—colonic wall thickening, pericolic fat stranding, inflammatory changes
Complicated—Extracolonic air, abscess, perforation
Table 24.2 Intra-operative classification.
hinchey Classifications
Type I—Diverticulitis with no or local peritonitis Type II—Diverticulitis with a small pericolic abscess Type III—Diverticulitis with local purulent or fecal peritonitis Type IV—Diverticulitis with diffuse purulent or fecal peritonitis
Table 24.3 Definitions of diverticular disease.
diverticulitis defined:
I Diverticulosis
1 Asymptomatic
II Diverticulitis
1 Noninflammatory
A Symptoms without inflammation
2 Acute
A Complicated Perforation, Abscess, Phlegmon, Fistula, Bleeding
B Uncomplicated (Simple) Localized, thickening, fat stranding
3 Chronic
A Recurring or persistent disease Symptoms with systemic signs (may be intermittent)
B Atypical Symptoms without systemic signs
4 Complex
A Fistula, Stricture, Obstruction
5 Malignant
A Severe, fibrosing
Trang 4disease, Thorson and Goldberg described the disease based on
the type of presentation, timing and duration of the disease, and
complexity.(10) (Table 24.3)
Acute Uncomplicated Diverticulitis
Nonoperative Treatment
Multiple reports have cited the successful treatment of
uncom-plicated diverticulitis in all patients, regardless of age.(11–16)
However, the treatment can be quite variable as cited in a recent
survey among members of the American Society of Colon and
Rectal Surgeons (ASCRS) (12)This survey found that the
treat-ment of patients with uncomplicated diverticulitis varied widely
between type and number of antibiotics used, feeding
sched-ule, and admission to the hospital Further study into the
nat-ural history of the disease, with respect to both the short- and
long-term outcomes of patients with uncomplicated
diverticu-litis, is overwhelmingly in favor of conservative treatment
with-out operation (13, 15–18) It is estimated that with conservative
treatment 70–100% of patients will improve Patients are even
being treated as outpatients with oral antibiotics, sports drinks,
and frequent follow-up in an effort to limit cost related to
uncomplicated disease (19)
Outcome Measures
Economic and morbidity models have been developed to
evalu-ate the cost and risk/benefit ratio of early versus levalu-ate operation for
patients with uncomplicated diverticulitis These studies
deter-mined that waiting, until after the 3rd or even 4th attack of
docu-mented diverticulitis, was both cost effective and less morbid on a
population based model, than performing an early elective
oper-ation (9, 20) Traditional teaching about diverticulitis suggested
that patients suffering more than two episodes of uncomplicated
diverticulitis should undergo an elective operation In fact, most
of the consensus data on elective resection after two documented
episodes comes from literature that was published before the use
of CT scanning and modern day antibiotic therapy Because of
these and other studies, the American Society of Colon and Rectal
Surgeons (ASCRS) has revised its previous recommendations of
resection The 2006 revised practice parameters now read, “The
decision to recommend surgery should be influenced by the age
and medical condition of the patient, the frequency and
sever-ity of the attacks, and whether there are persistent symptoms
after the acute episode.” (1) These new recommendations have
changed the traditional perspective taken on this disease process
and forces those involved in the care of patients with this disease
to reevaluate the literature and possibly modify their practice
Thus today, surgeons must individualize the recommendation
for operation for each patient One must take into account the
patient’s history, physical exam and diagnostic radiographic
find-ings, response to medical therapy and other comorbidities before
making recommendations for an operation
Progression of Disease
One of the most feared complications of diverticular disease is
the need for an emergent operation with possible fecal
diver-sion The increased morbidity and mortality to patients is not
insignificant when an emergent operation is required However,
the need for emergent fecal diversion most commonly occurs with a first episode of diverticulitis and is very rarely associated with recurrent disease It has been estimated that only 1 in every 2,000 pt/years of follow-up will require an emergent resection after resolution of an episode of medically treated diverticulitis (17) A recent meta-analysis reviewing the outcomes of medi-cally versus surgimedi-cally treated uncomplicated diverticulitis dem-onstrated that recurrent hospitalization was more frequent in the medically treated group than in a surgically treated one Mortality rates for uncomplicated disease were generally low though, regardless of the treatment chosen, especially in patients less than 50 years of age (21)
In addition to the fear of an emergent operation and possible stoma, elective operation has long been recommended based on risk of recurrence In the 1950s it was reported that morbidity and mortality were higher with recurrent attacks of acute inflam-mation and early interval resection was a means of avoiding those problems.(22–24) Recent studies have repeatedly shown that recommendations for prophylactic operation to prevent the need for an emergent operation are unfounded In patients with uncomplicated diverticulitis, Chautems followed 118 patients after a first attack of uncomplicated diverticulitis for 9.5 years Of these patients, 71% had no recurrent episodes and of those that did, none required emergent surgery.(25) In a population based study of over 20,000 patients admitted with nonoperatively man-aged diverticulitis only 5.5% required an emergent colectomy
or colostomy Younger patients in this study were found to be at higher risk than their older counterparts.(18) Other studies have also demonstrated that the risk of patients requiring an emergent operation from recurrent disease is much lower than previously thought (Table 24.4) The number of patients who would benefit from prophylactic colectomy to prevent a future emergent opera-tion consistently remains <5%
A step-wise progression of diverticular disease from diverticulo-sis to uncomplicated diverticulitis followed by complicated diver-ticulitis and finally complex disease such as fistula or obstruction is not the natural progression of this disease Patients may present at any stage of the disease ranging from asymptomatic to colovesicu-lar fistula without a history of previous attack Janes reported that the idea that patients should undergo elective resection to avoid
a colostomy is incorrect; such a concept can scare patients into
“elective surgery.”(17) Prophylactic sigmoid resection based on the premise of preventing the possibility of future colostomy does not appear to be founded on evidence-based principles
Age
Most studies define “young” patients as those <50 years of age Younger patients have been thought to have more virulent dis-ease, with a higher risk for recurrence and emergent operation Recent publications have questioned whether or not this is the case.(7, 15, 29–31) Nelson et al observed that in 234 patients
>50 years of age, with a mean follow-up of 4 years after a CT scan diagnosed episode of acute uncomplicated diverticulitis, only 10 patients (4.2%) returned with a complicated episode; of these, 5 (2.1%) required an emergent colectomy and colostomy (29) Anaya published a review of 25,058 patients hospitalized for
an initial episode of diverticulitis Of the 20,136 patients treated
Trang 5improved outcomes in colon and rectal surgery
nonoperatively, 19% developed a recurrence, with those >50 years
of age having a slightly higher recurrence rate (27% vs 17%, p <
.001) They projected that a policy of routine, elective colectomy
in a younger population after an initial episode would require
13 elective operations to prevent one emergent colectomy In this
large series, 73% of young patients resolved with medical
man-agement and never suffered a recurrence Only 7% of all patients
<50 ever require an emergent operation The risk of all patients
of any age requiring an emergency operation was 5.5%.(18)
These recurrence rates are significantly lower than previous
estimations which were >30% for younger patients Very few
patients requiring an emergent operation had been previously
diagnosed with or suffered from diverticulitis An estimated 75%
to 96% of patients presenting with peritonitis and requiring an
emergent operation have never been diagnosed with the disease
previously This supports the notion that operating on patients
with a history of acute diverticulitis to prevent complications of
acute disease is ineffective at achieving that goal.(2, 26–28)
Although it seems intuitive that patients with more years
to live relative to their older counterparts are at a higher risk
of recurrence, there is little evidence available to suggest that
younger patients have a more virulent disease process that
war-rants aggressive surgical intervention Despite the split over
recurrence, most groups recommend initial conservative treat-ment As mentioned before, risk/benefit models recommend withholding resection until after three or four recurrent doc-umented episodes There has also been a suggestion that no surgical treatment should be offered despite the number of uncomplicated episodes.(8)
Nonoperative therapy for patients with uncomplicated diver-ticulitis has been shown to be safe and effective in a majority of this population The ASCRS practice parameter on diverticular disease also affirms that there is no clear consensus regarding whether younger patients treated for diverticulitis are at increased risk for complications or recurrent attacks.(1)
Risk of Recurrence
The risk of recurrence following an attack of uncomplicated diverticulitis is low The range of recurrent episodes of diverticu-litis after one uncomplicated attack is 1.4–18% (13, 15, 16)Janes (17) reviewed 94 papers in an effort to review the evidence for rec-ommendations put forth for elective resection after two attacks of diverticulitis They concluded that there is inadequate evidence to suggest that complications are more likely to occur with each suc-cessive hospital admission, or that the likelihood of a successful response to medical treatment decreases (Table 24.5)
Table 24.5 Natural history studies of uncomplicated diverticular disease as reviewed by Janes.(1)
1st admit 1st admit 2nd admit 2nd admit ref Year # Pts f/u diagnosis all Operations Operation emergent recurrence Operation emergent
Table 24.4 Number of patients requiring urgent surgery who had a previous history of diverticular disease.
emergent Operation emergent Operation Pts Who Would have Benefited from Prophylactic Colectomy
ref Yr # pts elective Or all Pts Pts with hx of diverticulosis Pts with a hx of diverticulitis f/u in years
* Patients who had been hospitalized previously with diverticulitis.
Trang 6Acute Complicated Diverticulitis
Outcome Measures
When determining how best to treat patients presenting with
acute diverticulitis two questions need to be answered First, what
category of diverticulitis is present based on history and physical
examination and CT scan findings Second, what is the feasibility
and indication for operation versus medical therapy? With the
advent and availability of CT scanning and its wide spread use for
typical symptoms of diverticulitis we are better able to classify the
disease A patient presenting with an acute complicated episode
of diverticulitis typically will have findings of abscess, phlegmon,
or localized perforation on CT scan In a recent review of patients
presenting with complicated diverticulitis, 29.5% were found to
have a paracolic abscess, 22.3% an acute phlegmon, 13.4% a
fis-tula, 22.6% an obstruction or stricture and 44% a contained or
free perforation.(35)
Peritonitis, free intraabdominal air, or obstruction unrelieved
by other methods is an indication for operation Patients with
signs of peritonitis or hemodynamic instability are not
candi-dates for medical management and should be resuscitated and
taken to the operating room However, many patients
present-ing with an abscess, localized and contained perforation, or
phlegmon are candidates for conservative therapy These
indi-viduals should be evaluated for possible percutaneous drainage
with radiographic guidance Once stabilized, patients with
com-plicated diverticulitis should have a complete colon evaluation
and most should be scheduled for an elective operation The
American Society of Colon and Rectal Surgeons (ASCRS) have
recommended that, “Elective colon resection should typically
be advised if an episode of complicated diverticulitis is treated
nonoperatively.”(1) However, there is a growing body of
evi-dence to suggest that select patients with complicated disease
may be safely managed if they respond to more conservative
measures
Ambrosetti attempted a prospective trial of surgery versus
observation after the 1st complicated attack of diverticulitis but
abandoned the trial after 19 months as only 4 of the 52 (8%) had
a recurrence.(36)
Faramakis followed 120 patients from 30 centers over 5
years with complicated diverticulitis, defined as abscess,
fis-tula, obstruction, or free perforation Of these patients, 32%
developed a severe complication and 10 patients died However,
many of these patients were treated nonoperatively because they
were not felt to be surgical candidates and three times as many
patients died from cardiovascular or pulmonary complications,
compared to those who died from complications of diverticular
disease.(37)
One small study followed 28 patients after identification of
complicated disease on CT scan Ten patients were percutaneously
drained and the rest were treated conservatively Two patients
ulti-mately required operation during their initial hospitalization and
18 patients (24%) had recurrence They concluded that most
patients could be managed without an operation or drainage
(38) However, until more evidence substantiates a clear path to
follow, operative resection remains the standard for most patients
presenting with complicated disease
Risk of Recurrence—Indications for surgical treatment
Patients presenting with peritonitis should undergo an urgent operation after appropriate resuscitation Patients presenting with complicated disease without peritonitis should initially be treated conservatively with IV Fluids, NPO, antibiotics, and per-cutaneous drainage of any abscess Evaluation in a recent study identified 511 patients diagnosed with complicated diverticulitis
Of these patients, 99 were diagnosed by CT scan with abscess and
16 of these underwent percutaneous drainage Of those patients with continued nonoperative treatment, even after percutaneous drainage, a recurrence rate of 42% was noted with an increased probability of emergent procedure Based on these findings it was recommended that all patients with complicated findings on CT scan undergo an elective operation.(8)
Salem reviewed all hospitalized patients for the state of Washington After evaluating over 25,000 patients, percutaneous drainage and medical management were found to decrease the need for emergency operative interventions.(39)
Other studies have shown that complicated disease is not a result of multiple uncomplicated episodes Salem, et.al., demon-strated that of 77 patients followed with complicated diverticuli-tis, only eight had two or more previous episodes A majority of patients (79.4%) with fistula, perforation, bleeding, and abscess had no previous episodes of diverticulitis.They concluded that simple acute diverticulitis is not a good predictor for the develop-ment of further complications from diverticular disease as only a minority of patients with complications had previous episodes of diverticulitis.(13)
Chapmen found that only 21% of patients presenting with free perforation and peritonitis had a previous history of disease (40) Somasekar reviewed 108 patients admitted with complicated diverticulitis Of these, 104 required emergent surgery but only
28 patients had a previous history of uncomplicated diverticuli-tis However, only 3 (2.7%) of these 28 patients had suffered two previous episodes and would have qualified for an operation under the standard guidelines (2) Hart performed a case con-trolled study of patients presenting with perforated diverticulitis and found that 78% had no previous history.(41)
Timing for Surgical Intervention
Complicated diverticulitis is at this time an indication for opera-tion Circumstances may arise that would make continued obser-vation a wiser decision based on the age and comorbidities of the patient, but until further evidence is available operation contin-ues to be the standard of care
Pain is a valuable indicator for the patient’s recovery, and pro-vides a marker for evaluation Attempts at initiating PO intake and switching antibiotic therapy may be confidently made based on the patient’s symptoms or lack of resolution of those symptoms
Once the patient is pain free and has undergone an adequate preoperative evaluation, surgery can be undertaken Before any surgical procedure patients should undergo endoscopic evalua-tion of the colon in order to rule out other disease processes that may need to be taken care of at the same time Optimal timing for performing an operation after medical treatment of a complicated
Trang 7improved outcomes in colon and rectal surgery
episode of diverticulitis has occurred and has never been studied
However, it seems prudent to offer an elective operation within
6 to 8 weeks to allow the inflammatory process to settle and
pro-vide an opportunity for safest operation Laparoscopic surgery
will also be easier without the inflammatory component of the
acute setting
Chronic Diverticulitis
Indications for Medical versus Surgical Treatment
Chronic diverticulitis is typically defined as uncomplicated acute
diverticular disease that resolves with antibiotic therapy only to
flare again once antibiotics are discontinued It is not a
particu-larly common entity within the spectrum of diverticular disease
Patients initially respond well to antibiotic therapy but fail to
fully resolve their symptoms, or have frequent recurrences within
weeks of each other Patients may experience multiple flares of
the disease that resolve spontaneously but continue to plague the
patient for weeks to months
Indications for surgical treatment
Chronic diverticulitis is an indication for operation However, the
correct diagnosis of recurrent or chronic diverticulitis must be
secure Chronic abdominal pain unrelated to diverticular disease
has been described and an operation for pain without
confirma-tory findings is doomed to failure Barium enema may be the
colon clearing test of choice in this situation as colonoscopy can
be associated with an increased risk of perforation in the face of
smoldering diverticular disease
Best Timing for surgical intervention
Ideally, patients should be continued on their antibiotics up to
the time of operation A bowel prep should be instituted in these
patients and their nutritional status be reassessed depending on
the amount of time they have had a chronic smoldering infection
and been unable to eat A good starting place is to simply evaluate
the amount of weight lost over the recent past Patients may be
candidates for either laparoscopic or open surgery, as both have
been shown to be safe and effective in the hands of well practiced
surgeons
Complex Diverticulitis
Indications for surgical treatment
Complex diverticulitis is defined as patients with colonic
fis-tula, stricture or obstruction Colovesicular fistulas are the most
common fistula, but colosalpingo, colocutaneous, colo-colo,
colovaginal, and coloenteric fistulas all have been reported as a
complication of diverticular disease Bleeding divertula is not
typically associated with the inflammatory state of diverticulitis
and thus falls outside the scope of this chapter
About 1–2% of patients with diverticulitis develop an internal
fistula.(6) Symptoms of fistula depend on the location Dysuria,
fecaluria, and pneumaturia are the most common presenting
signs for colovesicular fistula At times, symptoms go unnoticed
and a delay in diagnosis for a prolonged period of time is not
uncommon Rarely, some patients who present with complex
diverticulitis have never formally been diagnosed with previous
episodes of diverticulitis This may be because the patient never sought medical attention despite having some symptoms, or the symptoms were mistaken for gastroenteritis, or other such ail-ment Complications of diverticular disease appear to be related more to the severity of the attack at a specific location than from progression from simple to complex disease in an orderly fash-ion This inflammatory process may range from uncomplicated
to complex
Contrast enema has been described as one of the ways to diag-nose an abnormal connection between the colon and another organ However various reports put the success rate between 34–83%.(42, 43) Vaginography or cystoscopy are two other ways
to confirm the diagnosis If suspicions are still present with rel-evant symptoms, and CT scan confirms diverticulitis, operation can be offered without confirmatory testing
Whatever the source, patients with complex diverticulitis should undergo an operation to correct the problem, unless the patient is not a surgical candidate These patients who are not surgical candidates can be managed on suppressive antibiotics One important concept to remember is that fistulas do not rep-resent an emergency If the patient is appropriately draining, and does not appear to be septic, there is no emergency to the tion Complex fistulas have been managed with a single opera-tion successfully in as many as 90% of cases, both with open and laparoscopic techniques.(44–46)
Obstruction from diverticular disease is quite different Patients who present completely obstructed from diverticular disease will require urgent decompression Depending on the stability of the patient, multiple options including resection and primary anasto-mosis with or without proximal diversion, Hartmann procedure, Turnbull colostomy, or stent placement are available for the sur-geon These patients may carry an extensive history of diverticular disease Ruling out other sources of obstruction, specifically colon cancer, is important If the patient has not been screened appro-priately, one may choose to perform intraoperative colonoscopy depending on the patient’s condition and state of the bowel If this
is impossible during the operation, as is frequently the case, then follow up colonoscopy should be undertaken after the operation
iMMunOsuPPressed PaTienTs Risk of developing diverticulitis
Difficulty arises in attempting to diagnosis diverticulitis in an immunocompromised patient because many fail to manifest the classical signs and symptoms of the disease Patients who are considered to be immunosuppressed include transplant recipi-ents, those with an immunodeficiency syndrome, or those taking immunosuppressive medications for arthritis, autoimmune dis-eases, or inflammatory bowel disease Patients who are especially problematic are those that are receiving prednisone in dosages
>20 mg/day They present with fewer symptoms, have a longer time to operation, and higher mortality (85%) when compared with patients receiving lower doses (13%).(47) Thus, any patient taking higher doses of an immunosuppressive medication must be considered immunosuppressed and evaluated accordingly These patients are much more likely to present with a free perforation than their nonimmunocompromised patients.(48–50) Correlation
Trang 8between a delay of diagnosis and mortality has also been
demon-strated in these patients
Transplant patients make up an ever growing population that
requires immunosuppressive medication The incidence of
trans-plant diverticulitis varies by the type of transtrans-plant performed;
however, all studies show a low incidence of the disease One
report reviewed 2,000 patients over a period of 30 years following
renal transplants and reported a 0.5% risk of any colonic
prob-lems including diverticulitis.(51)
Many studies have reported an incidence of diverticulitis
among both lung and heart transplant patients that varies from
0.75% to 4% However the hospital admission rate for
diverticu-litis in a “normal” population is 25–50 per 100,000 admissions
(0.025–0.053%), which is much less than in a transplant
popula-tion.(51–53) From 1985 to 1996, a review of six series including
986 of heart and lung transplant patients showed an incidence
of 0.75% The authors concluded that pretransplant screening of
diverticulosis is not justified in the absence of symptoms.(54)
Other authors have evaluated their experience with
compli-cated diverticulitis in renal transplant patients Of 1,211 patients,
13 patients had episodes of diverticular disease for a 1.1%
inci-dence They concluded that the problem is rare but the clinical
presentation is atypical.(55)
One of the major benefits among the transplant population
was the introduction of cyclosporine because of the decreased
steroid requirement It has been demonstrated that a nearly
50% decrease in the rate of complicated diverticulitis was
accomplished in patients who were treated with cyclosporine;
however, this did not reach statistical significance due to small
sample size.(55)
Prophylactic Sigmoid Resection
Most authors recommend that patients with symptomatic
diver-ticulitis with appropriate confirmation undergo sigmoid
resec-tion before transplant Diverticulosis without symptoms though
does not require further investigation and is not an indication for
prophylactic resection However, these patients are at a slightly
higher risk than the general population and should be monitored
closely.(55) Postoperative mortality is high in
immunocompro-mised patients who develop acute diverticulitis requiring
opera-tive intervention An increased index of suspicion is necessary in
treating immunocompromised patients An approach
incorpo-rating an aggressive evaluation with medical support and early
surgical exploration is generally warranted
One specific population deserves mention and those are
patients with polycystic kidney disease These patients appear to
have a higher incidence of complicated diverticulitis than other
transplant patients, and one study concluded that these
individu-als warrant more aggressive diagnostic evaluation for any
symp-toms Pretransplant screening and prophylactic sigmoid resection
deserve further study.(55)
OPERATIVE MANAGEMENT
What manner of operation is best?
Three operations are typically recommended for patients
requir-ing a sigmoid resection Open sigmoid resection, laparoscopic
sigmoid resection, or hand assisted laparoscopic resection (HAL) Despite the recent eruption of literature and discussion about the benefits of laparoscopic colectomies, only 5–10% of all colecto-mies are currently performed using a laparoscopic technique.(56) However, with increased training and utilization, it is anticipated that this number will continue to increase substantially
Open colectomy is the gold standard for comparison Laparoscopic colectomy has gained increased prominence fol-lowing the successful application of this technique for other pro-cedures While it is still in its infancy, it is fast becoming the main choice for a growing number of patients and surgeons Many large studies have been undertaken to assess the safety of laparo-scopic colectomy as well as its economic feasibility
Reported benefits of laparoscopic colectomy include shorter hospital stay, less postoperative pain, earlier return of bowel func-tion, and quicker return to daily activities Other reported benefits include less wound, respiratory, gastrointestinal, and cardiopul-monary complications when compared to open surgery.(57–60) The downsides of laparoscopic surgery include surgeon specific initial higher complication rates and conversion rates associated with a steep learning curve, longer operating room time, and higher cost for operations.(58) However, a recent study looking directly at total cost for open sigmoid resection versus laparo-scopic sigmoid resection by Senagore (59), revealed that overall total costs were significantly lower for laparoscopic patients, and that operating room costs were not different between the two types of surgery They concluded that laparoscopic resection was
a cost effective means of managing sigmoid diverticular disease
A key factor to keeping the costs equivalent between open and laparoscopic resection was the minimization of conversion and complication rates A conversion rate of 6.6% was observed in this study
However, many factors go into a study like this including rou-tine postoperative care, and surgeon and patient comfort levels with earlier discharge Despite this, slow but steady progress in training of younger surgeons and greater familiarity with the new techniques will more than likely make laparoscopic surgery the standard of care in the future, much as laparoscopic cholecystec-tomy has become
Hand Assisted Laparoscopic (HAL) Colectomy has also been compared against laparoscopic resection and been found to be equivalent as far as outcome of patients.(56, 61) Benefits of HAL have been shorter operating times when compared with straight laparoscopic surgery as well as lower conversion rates One recent study identified an advantage to using HAL colectomy with com-plicated diverticulitis and laparoscopic resection for uncompli-cated diverticulitis.(56) The cost of utilizing a hand port was not significantly different when offset by the faster operating room time.(61)
Much depends on the ability of the surgeon to complete the case without conversion Conversion rates increase the total cost of the operation as well as the potential morbidity rates for the patient
In an article by Belizon (60) an analysis was made of patients undergoing conversion to an open operation Postoperative mor-bidity was significantly higher for laparoscopic resection pro-cedures that were converted to open after 30 minutes into the
Trang 9improved outcomes in colon and rectal surgery
operation Wound complications and greater length of stay in the
hospital were the two most common findings Obesity, adhesions,
bleeding, and inflammation beyond area of operation were the
most common predictors for conversion
The best operation for an individual seems to be the
opera-tion the surgeon can perform However, with advancing
mini-mally invasive techniques that can be implemented at a similar
cost structure, it behooves all surgeons to continue to educate and
modify their practices to provide the best care possible to their
patients
Which Operation is Best?
Three different operations have been proposed for the treatment
of complicated diverticulitis with peritonitis The first operative
approach described was the three stage procedure
encompass-ing drainage with stoma, followed by resection and anastomosis
with continued diversion, and finally by restoration of
continu-ity The second approach involved resection and diversion or the
traditional Hartmann procedure (HP) However, this approach is
being challenged by the third approach of resection with primary
anastomosis Primary resection with anastomosis (PRA) can be
performed with or without a covering stoma, and/or on-table
lavage The three stage procedure will not be discussed here as it
is not considered standard of care and should be used only in very
infrequent situations
In 1921, Hartman advocated his two stage resection which was
superior and quickly became the standard of care However early
in the 1960s there were eight reports with a total of 50 patients
that underwent resection and primary anastomosis for
general-ized peritonitis with a low mortality of 10%.(63) Not much debate
is raised now with respect to patients presenting with recurrent
or chronic diverticulitis They are typically managed in an elective
fashion with primary anastomosis Patients are still traditionally
given a bowel preparation before surgery, at least in the United
States, and probably will for some time though there is a growing
swell within the literature questioning its necessity
Patients who present with acute symptoms, typically Hinchey
stages III or IV, are taken to the operating room urgently These
patients constitute approximately 3.2 per 100,000 patients.(63)
These patients present a dilemma, because typically they are
older, have a high number of comorbidities, and suffer a greater
number of complications In a recent review by Salem reviewing
98 articles on the outcome of complicated diverticulitis based on
the type of operation performed, they identified 1,051 patients
who underwent a Hartmann procedure from 54 studies, and
569 patients having undergone a primary anastomosis from 50
studies (Tables 24.6 and 24.7) Of the patients undergoing a
pri-mary anastomosis, 16% had covering stomas and 10% had
on-table lavage The mortality rates of those in the Hartmann group
(19.6%) were much higher than those undergoing a primary
anastomosis (9.9%) The anastomotic leak rate in patients with
a primary anastomosis ranged from 6.3% to 19.3% If a diverting
proximal stoma was performed at the time of a primary
anas-tomosis the anastomotic dehiscence rate fall to 6.3% Wound
infections were also more frequently seen in the Hartman group
(24.2%) versus the primary anastomosis group (9.6%) Again,
patients with covering stomas had the lowest wound infection rate
at 4% Patients undergoing a Hartmann procedure also required
a larger second operation than those who had PRA with or with-out a covering stoma Complications from a Hartmann reversal were associated with a mortality of 0.8%, a wound infection rate
of 4.9% and an anastomotic leak rate of 4.3% These patients also experienced stoma complications (10.3%) that required medi-cal attention The conclusion was the primary anastomosis is no worse than a Hartmann procedure and has several advantages including higher restoration of continuity rate, less hospitaliza-tion, and fewer infectious complications.(64)
Multiple studies have evaluated the morbidity and mortality of the Hartmann procedure as well as the risks incumbent with takedown Most seasoned surgeons realize that at times restoration of continu-ity can be more of a challenge to both patient and surgeon than the original operation This was demonstrated in a recent multicenter prospective trial involving 415 patients with complicated diverticuli-tis Two hundred forty-eight patients underwent resection with pri-mary anastomosis The other 167 had a Hartmann procedure The mortality rate for those undergoing primary anastomosis was 4.0% while those with resection and diverting colostomy was 23.4% After case adjustment, the data suggested that the Hartmann procedure was associated with a 1.8 fold increase in likelihood of death This was not statistically significant However a 2.1 fold increase in morbidity was found between the two groups and this was significant In part this is due to the fact that surgeons typically reserved a Hartmann procedure for those older patients with more comorbidities and thus predisposed to a poorer outcome.(65)
Risks associated with Hartmann Reversal
Reversal of a Hartmann colostomy also carries with it a signifi-cant risk that must be entertained when considering this opera-tion for patients who will desire continuity in the future Failure
Table 24.7 Outcomes of Hartmann and Hartmann Reversal
Salem et al (61)
# of Patients Mortality
Wound infection
stoma Complications leaks
Hartman Reversal
Table 24.6 Outcomes of primary anastomosis in patients with
complicated diverticulitis—Salem et al.(61)
Primary Primary Primary Primary with anastomosis anastomosis anastomosis anastomosis Overall alone with stoma lavage
Trang 10to reverse the colostomy has been reported in 20–50% (61) of
patients and leak rates on reversal fall around 2–30% (61, 63)
Mortality has been reported anywhere from 0–10% and wound
infection rates range from 12–50%
A strong interest in primary anastomosis has been revived in
the literature, with papers describing the successful outcomes of
patients undergoing this type of operation However, few papers
are prospective, less are randomized, and such a trial is still needed
today to definitively answer the questions of safety and efficacy
Multiple trials though have shown that the outcomes of primary
anastomosis are indeed as safe as a Hartman and in many cases
better In a recent review, Constantinides et al reviewed the
out-comes of patients undergoing Hartmann (66), primary resection
with anastomosis (PRA) (135 patients) and primary resection
with anastomosis and diversion (126 patients) Patients
under-going a Hartmann procedure had a morbidity and mortality
of 35% and 20% respectively Primary anastomosis showed a
slightly higher morbidity and mortality at 55% and 30%, while
those with a primary anastomosis with diverting stoma
demon-strated a morbidity and mortality rate of 40% and 25%
respec-tively Stomas were permanent in 27% of patients undergoing a
Hartmann procedure and 8% of those having a primary
anasto-mosis with diversion They concluded that primary anastoanasto-mosis
with defunctioning stoma may be an optimal strategy for selected
patients Hartmann procedure should be reserved for patients
with an extremely high risk of perioperative complications and
only after consideration of long-term implications.(63)
Patients undergoing on-table lavage have been analyzed as well,
which showed similar outcomes to those who did not undergo
on-table lavage Regenet, described 60 patients, all Hinchey III or
greater, in whom 27 underwent primary anastomosis with
intra-operative lavage and 33 who had a Hartmann procedure In this
prospective observational study they found that the Hartmann
procedure took much less time to perform, but that the
mortal-ity and morbidmortal-ity for both groups were equal Three patients in
the intraoperative lavage group had an anastomotic leak (11%)
A Hartmann reversal occurred in 69% of the patients The
rever-sal had its own associated morbidity of 24%, an anastomotic leak
rate of 7%, and no deaths Postoperative stay after primary anas-tomosis and intraoperative lavage was 18.4 days and Hartmann Procedure was 38 days They concluded that primary anasto-mosis with intraoperative lavage and a Hartmann Procedure are both adequate approaches for generalized peritonitis complicat-ing diverticulitis.(17)
Covering stomas have been recommended by most studies when primary anastomosis is performed because of the variable anastomotic leak rate Both diverting colostomies and ileostomies have been described with equal success Most of the poor out-comes noted are not necessarily due to the operation performed, but the comorbidities and peritonitis associated with the patient and disease These risks play more into the outcome of patients than the type of operation performed
Complications of Operation
Predictors of Morbidity and Mortality—Scoring Systems
Multiple scoring systems have been evaluated in attempts to pre-dict outcome and risk in patients undergoing both elective and emergent colon resection for diverticulitis With an increasing interest in outcomes by doctors, patients, and payers, predictive scoring systems may be one of the many ways surgeons, hospitals, and systems are evaluated
Developed by Copeland in 1991, the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) was developed as a tool to compare mor-bidity and mortality in a wide range of general surgical proce-dures This was to facilitate surgical audit and the comparison
of hospital performance It has been further adapted for patients undergoing colon and rectal surgery and named cr-POSSUM (Table 24.8) The idea was to adjust risk of a surgical procedure based on the patient’s physiological condition and therefore allow a more accurate comparison of a unit (or individual’s) performance
Oomen has been one of the physiological and operative sever-ity score (POSSUM) score’s biggest proponents and has done
a number of studies attempting to validate the system When
Table 24.8 The cr-POSSUM scoring system.
Physiologic Parameters
Operative Parameters