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157. Diverticular Disease Management [SKF]

Diverticular Disease Management

Introduction

  • Diverticulitis is a common inflammatory condition of the gastrointestinal (GI) tract.
    • Approximately 300,000 hospital admissions per year in the U.S.
    • Among the top five most costly GI diseases.
  • Knowledge gaps and controversies exist in:
    • Pathophysiology
    • Triggering factors
    • Effective treatments
    • Surgical indications
    • Role of antibiotics in uncomplicated disease
  • Recent reconsiderations in understanding:
    • Diverticulitis may not be just acute episodes followed by asymptomatic periods.
    • Some patients experience chronic, waxing and waning symptoms.
  • Patient education is critical due to misinformation about diet and treatment.

Terminology

Diverticulosis

  • Diverticula: Saccular outpocketings of the colonic wall.
    • False diverticula: Involve only mucosa and muscularis mucosae (common in the West).
    • True diverticula: Involve all layers of the bowel wall (more common in Asia).
  • Prevalence:
    • Rare under age 30.
    • Increases with age; majority affected by age 80.
    • Equally prevalent in men and women in industrialized nations.
  • Symptoms:
    • Most individuals are asymptomatic.
    • Often diagnosed incidentally during screening colonoscopy.
  • Patient Misconceptions:
    • Confusion between diverticulosis and diverticulitis.
    • Unnecessary lifestyle changes or seeking surgical advice without symptoms.

Diverticular Disease

  • Definition: Any symptoms related to the presence of diverticulosis.
  • Manifestations:
    • Diverticular bleeding
    • Acute diverticulitis
    • Symptomatic Uncomplicated Diverticular Disease (SUDD)
    • Segmental Colitis Associated with Diverticulosis (SCAD)

Diverticular Bleeding

  • Cause:
    • Injury to a diverticulum leads to intimal thickening, scarring, and irritation of the vasa recta.
    • Results in bleeding into the colon lumen.
  • Clinical Features:
    • Profuse, episodic lower GI bleeding.
    • Accounts for 10%–30% of GI bleeds requiring attention.
    • Bleeding often stops without intervention but may require endoscopic, radiologic, or surgical treatment.

Acute Diverticulitis

  • Definition: Inflammation of one or more diverticula.
  • Symptoms:
    • Left lower quadrant abdominal pain
    • Malaise
    • Low-grade fevers
    • Leukocytosis
  • Pathogenesis:
    • Historically thought due to obstruction by particulate matter or fecaliths.
    • Leads to inflammation and microperforation.
  • Complications:
    • Formation of a phlegmon or abscess.
    • Possible progression to bacteremia or sepsis.
    • Formation of fistulas if abscess erodes into adjacent organs.
    • May cause ileus, leading to nausea and crampy abdominal pain.

Symptomatic Uncomplicated Diverticular Disease (SUDD)

  • Characteristics:
    • Chronic, low-grade abdominal pain.
    • Pain can be colicky or constant.
  • Diagnosis:
    • Made after excluding acute diverticulitis, irritable bowel syndrome (IBS), and SCAD.
  • Understanding:
    • Represents a chronic variant of diverticular disease.
    • Previously termed chronic smoldering diverticulitis or atypical diverticulitis.

Segmental Colitis Associated with Diverticulosis (SCAD)

  • Definition: Localized inflammation of diverticula resembling inflammatory bowel disease (IBD).
  • Features:
    • May be a precursor or variant of IBD.
    • Also known as diverticular colitis.
    • Can present with milder inflammatory changes.

Pathophysiology and Epidemiology

Incidence

  • Historical Context:
    • Rarely mentioned before 1880.
    • Now the sixth most common GI outpatient diagnosis in the U.S.
    • Most common GI diagnosis on hospital discharge.
  • Economic Impact:
    • Over 300,000 hospital admissions annually in the U.S.
    • Estimated treatment costs of $2.5 billion per year.
    • Approximately 3400 deaths annually.
  • Age Factor:
    • More common in older patients.
    • Incidence increases with aging population.
  • Trends:
    • Hospital discharges for diverticulitis increased by 50% over 15 years.
    • Significant increase in younger patients (<44 years old).

Pathophysiology

  • Unclear Etiology:
    • Relationship between diverticulosis and diverticulitis is not fully understood.
    • Possible factors include colonic structure, motility, and diet.
  • Geographic Variations:
    • Western patients: Diverticula mainly in sigmoid and descending colon.
    • Asian patients: Diverticula often in the right colon.
    • Migration and dietary changes influence disease patterns.

Diet

  • Low-Fiber Diets:
    • Associated with increased risk of diverticulosis.
    • Leads to smaller stools and higher intracolonic pressures.
  • Studies:
    • Higher fiber intake correlates with lower risk of symptomatic diverticular disease.
    • Vegetarians may have a lower risk compared to non-vegetarians.
  • Red Meat Consumption:
    • Positively associated with the risk of symptomatic diverticular disease.

Properties of the Colon Wall

  • Structural Changes:
    • Increased elastin deposition in the colon wall.
    • Leads to stiffening and decreased elasticity.
  • High Intraluminal Pressure:
    • Sigmoid colon has the smallest radius, generating higher pressures.
    • Predisposes to formation of diverticula due to weak points.

Altered Colon Motility

  • Hypersegmentation:
    • Simultaneous contraction of neighboring haustra increases pressure.
  • Hypothesis:
    • High pressures cause focal muscle atrophy, permitting mucosal herniation.
  • Role of Interstitial Cells of Cajal:
    • Reduced numbers in patients with diverticulosis.
    • Leads to disorganized colonic contractions and elevated pressures.

Triggers of Inflammation

Fecal Stasis

  • Slow Transit:
    • Delayed movement of feces through the colon.
  • Entrapment:
    • Difficulty expelling stool from diverticula due to lack of musculature.
  • Consequences:
    • Alteration of intestinal flora.
    • Local ischemia.
    • Mechanical breakdown of the colon wall.

Bacterial Flora

  • Altered Microbiome:
    • Low-fiber, high-fat diets change bacterial populations.
    • Increased Bacteroides colonies.
  • Inflammation:
    • Altered flora may diminish mucosal barrier function.
    • Leads to upregulation of inflammatory cytokines.
    • May contribute to chronic inflammation affecting the enteric nervous system.

Risk Factors

Age

  • Older Age:
    • Higher prevalence of diverticular disease.
  • Younger Patients:
    • Previously thought to have more virulent disease.
    • Recent studies show similar severity but higher recurrence rates.

Obesity

  • Increased Risk:
    • Higher body mass index (BMI) associated with increased risk.
    • Women with BMI ≥30 have twice the risk of complicated diverticulitis.
  • Possible Mechanism:
    • Elevated inflammatory cytokines from adipose tissue may exacerbate colon inflammation.

Exercise

  • Protective Effect:
    • Regular strenuous activity reduces risk.
  • Studies:
    • Higher physical activity linked to decreased risk of diverticulitis and bleeding.
  • Sedentary Lifestyle:
    • Increased sitting time associated with higher risk.

Nonsteroidal Antiinflammatory Drugs (NSAIDs)

  • Association:
    • Increased risk of diverticulitis and diverticular bleeding.
  • Mechanism:
    • Altered colon permeability decreases wall integrity.

Medications (Corticosteroids)

  • Risk of Perforation:
    • Chronic use may reduce collagen turnover.
  • Studies:
    • Threefold increased risk of perforation in corticosteroid users.

Seasonal Variation

  • Higher Admissions:
    • Increased cases during summer months.
  • Possible Factors:
    • Ultraviolet light exposure affecting vitamin D levels.

Immune Status

  • Immunocompromised Patients:
    • More likely to have atypical presentations.
    • Higher risk of complications like free perforation.
  • Management Challenges:
    • Higher mortality rates.
    • Importance of prompt diagnosis and treatment.

Smoking

  • Effects of Nicotine:
    • Decreases collagen formation.
    • Increases colonic motility and intraluminal pressure.
    • Impairs mucosal blood flow.
  • Risk Increase:
    • Smokers have higher risk of perforation or abscess formation.

Alcohol

  • Increased Risk:
    • Consumption of >1 ounce (30 grams) daily linked to higher risk.
  • Unclear Mechanism:
    • Pathway to diverticulitis development not well understood.

Family History

  • Genetic Susceptibility:
    • Family history increases risk of diverticular disease.
  • Studies:
    • Higher odds of developing diverticulitis if a twin or family member is affected.

Summary

  • Diverticulitis is a complex disease with increasing incidence and significant health impact.
  • Understanding pathophysiology is key to management.
  • Lifestyle factors like diet, exercise, and smoking play significant roles.
  • Patient education is essential to correct misconceptions and promote effective prevention and treatment strategies.
  • Risk factors should be considered in both prevention and management plans.

Key Takeaways

  • Diverticulosis is common and often asymptomatic; patients without symptoms do not need lifestyle changes.
  • Diverticular disease encompasses various conditions related to diverticula, including bleeding and inflammation.
  • Dietary fiber intake is inversely related to the risk of diverticular disease.
  • Regular physical activity may reduce the risk of diverticulitis.
  • NSAIDs and corticosteroids increase the risk of complications.
  • Smoking and obesity are modifiable risk factors associated with increased risk.
  • Family history is an important non-modifiable risk factor.
  • Prompt diagnosis and management are crucial, especially in immunocompromised patients.

Diagnosis of Diverticular Disease

Overview

  • Diverticular disease has varied presentations, from asymptomatic diverticulosis to severe complications like peritonitis.
  • Diverticulosis: Presence of uninflamed diverticula; generally asymptomatic.
  • Symptomatic presentations can range from crampy discomfort to severe abdominal emergencies.

History and Physical Examination

Diverticulosis

  • Asymptomatic in most patients.
  • Often an incidental finding during screening colonoscopy.
  • Patient Education:
    • Reassure that diverticulosis is typically benign.
    • Address confusion and unnecessary concerns.

Diverticular Bleeding

  • Presents as massive hemorrhage per rectum.
    • Occult bleeding is less common.
  • Symptoms:
    • Typically painless bleeding.
    • Rarely associated with abdominal pain.

Symptomatic Uncomplicated Diverticular Disease (SUDD)

  • Pathophysiology: Unclear.
  • Symptoms:
    • Colicky or constant abdominal pain.
    • Pain relieved by passing flatus or bowel movements.
    • Left lower quadrant tenderness; may have a palpable mass.
    • Fullness or bloating.
    • Changes in bowel habits:
      • Constipation more common than diarrhea.
  • Diagnosis:
    • Exclude acute diverticulitis and overt colitis.
    • Differentiate from Irritable Bowel Syndrome (IBS).

Acute Diverticulitis

  • Classic Presentation:
    • Left lower quadrant abdominal pain.
    • Changes in bowel habits: Constipation, loose stools, or mucous stools.
    • Low-grade fevers.
    • Fullness in lower abdomen or rectum (due to sigmoid colon inflammation).
    • Anorexia, nausea, and vomiting may occur.
    • Stool may be guaiac positive.
  • Patient History:
    • Prior episodes of diverticulitis are common.
    • Patients may self-identify symptoms based on past experiences.

Complicated Diverticulitis

  • Associated Symptoms:
    • Generalized abdominal pain (suggestive of free perforation).
    • Obstructive symptoms:
      • Abdominal distention.
      • Nausea and vomiting.
      • Caused by reactive ileus or phlegmon affecting the small bowel.
    • Urinary symptoms:
      • Urgency and frequency due to colon inflammation impinging on the bladder.
    • Other complications:
      • Hepatic abscess via mesenteric spread.
      • Septic arthritis of the hip due to progression of infection.

Fistula Formation

  • Colonic Fistulas: Develop during complicated diverticulitis.
  • Common Types:
    • Colovesical Fistula:
      • Accounts for two-thirds of diverticular fistulas.
      • Symptoms:
        • Pneumaturia (air in urine).
        • Fecaluria (feces in urine).
        • Recurrent urinary tract infections.
        • Changes in urine color.
      • Diagnosis:
        • CT scan showing air in bladder (if no recent instrumentation).
    • Colovaginal Fistula:
      • More common in women post-hysterectomy.
      • Symptoms:
        • Passage of feces or air from the vagina.
    • Enterocolonic Fistula:
      • Less common.
      • May cause diarrhea or abdominal cramps.
  • Clinical Concern:
    • Decreased surgical interventions may lead to increased fistula rates (data lacking).

Laboratory Studies

  • Complete Blood Count (CBC):
    • Assess for leukocytosis (present in 55% of acute diverticulitis cases).
  • Basic Metabolic Panel:
    • Evaluate electrolytes and kidney function.
    • Important if there's altered fluid or nutrition intake.
  • Urinalysis:
    • Helps evaluate for urinary tract infections.
    • Assists in diagnosing colovesical fistula.
  • C-Reactive Protein (CRP):
    • CRP >50 mg/L with left lower quadrant tenderness and no vomiting is suggestive of acute diverticulitis.

Imaging Studies

Purpose

  • Confirm the diagnosis.
  • Determine the location and extent of inflammation.
  • Identify complications (abscess, phlegmon, fistula).

Computed Tomography (CT) Scan

  • Test of Choice for diagnosing diverticulitis.
  • Advantages:
    • High diagnostic accuracy:
      • Sensitivity: 94%
      • Specificity: 99%
    • Evaluates:
      • Bowel wall thickening
      • Fat stranding
      • Abscesses
      • Free or intramural air
      • Inflammation of diverticula
      • Phlegmon
    • Can rule out other conditions.
  • Disadvantages:
    • Ionizing radiation exposure.
    • Higher cost.

Ultrasound

  • Alternative imaging modality.
  • Advantages:
    • No radiation exposure.
    • Useful in pregnant patients or those needing to limit radiation.
  • Diagnostic Accuracy:
    • Sensitivity: 92%
    • Specificity: 90%
  • Limitations:
    • Less effective in identifying large abscesses.
    • Difficulty detecting free air.

Contrast Studies (Gastrografin/Barium Enema)

  • Limited role in acute diverticulitis.
  • Uses:
    • Evaluating diverticulosis.
    • Identifying:
      • Luminal narrowing
      • Bowel tethering
      • Colonic strictures
      • Colonic fistulas
  • Cautions:
    • Risk of contrast leak into abdomen if perforation is present.
    • Water-soluble contrast preferred if perforation or malignancy is suspected.

Magnetic Resonance Imaging (MRI)

  • Accurate and sensitive for diagnosing acute diverticulitis.
  • Advantages:
    • No ionizing radiation.
    • Better soft tissue delineation.
  • Disadvantages:
    • Higher cost.
    • Longer imaging and processing times.

Cystography

  • Use:
    • Diagnosing colovesical fistula.
    • Rule out other causes of fistula.
  • Limitations:
    • Fistulas may be difficult to visualize.
    • CT scan often preferred; air in bladder on CT is diagnostic if no recent instrumentation.

Endoscopy

  • Generally discouraged during acute diverticulitis.
    • Risk of perforation or exacerbating inflammation.
  • Post-Recovery Use:
    • Colonoscopy recommended after resolution to:
      • Exclude malignancy (e.g., adenocarcinoma in 3%–5% of cases).
      • Rule out Inflammatory Bowel Disease (IBD).

Classification Systems

Hinchey Classification

  • Developed in 1978 by Hinchey et al.
  • Stages:
    • Stage I: Pericolic abscess or phlegmon.
    • Stage II: Pelvic, intraabdominal, or retroperitoneal abscess.
    • Stage III: Generalized purulent peritonitis.
    • Stage IV: Generalized fecal peritonitis.
  • Limitations:
    • Does not classify less severe disease without abscess.
    • Lacks inclusion of abscess location.
    • Not prospectively validated against clinical outcomes.
  • Correlation:
    • Significant correlation with intraoperative findings in perforated diverticulitis.

Hansen and Stock Classification (1998)

  • Usage: Widely used in Germany.
  • Features:
    • Includes asymptomatic diverticulosis.
    • Grades complicated diverticulitis by severity.
  • Acceptance:
    • Not widely adopted in North America or globally.

Need for a Practical System

  • An ideal classification would:
    • Predict chronic illness or quality of life outcomes.
    • Accurately predict medical treatment failure or risk of complicated disease.
  • Current State:
    • No universally accepted classification meets all needs.
    • CT imaging advancements have led to more detailed classifications.

Clinical Features and Differential Diagnosis

Varied Presentations

  • Symptoms depend on:
    • Degree of disease.
    • Patient factors.
    • Comorbidities.
  • Important Consideration:
    • Diverticulitis may transition from acute episodes to chronic, smoldering disease.

Common Symptoms

  • Lower abdominal pain or pressure, typically in the left lower quadrant.
    • Sigmoid colon redundancy can cause right-sided or pelvic pain.

Differential Diagnosis

  • Conditions to Consider:
    • Appendicitis
    • Bowel obstruction
    • Colorectal cancer
    • Gynecologic diseases (e.g., ectopic pregnancy)
    • Kidney stones
    • Ischemic colitis
    • Inflammatory Bowel Disease (IBD)
    • Irritable Bowel Syndrome (IBS)
    • Urinary tract infection/Pyelonephritis
    • Pneumonia
    • Cystitis

Acute Diverticulitis

  • Symptoms:
    • Left lower quadrant abdominal pain
    • Malaise
    • Low-grade fevers
    • Leukocytosis
  • Complications:
    • Microperforation leading to:
      • Phlegmon
      • Abscess
      • Potential progression to bacteremia or sepsis.

Chronic Diverticulitis

  • Characteristics:
    • Chronic symptoms lasting at least 2 months.
    • Symptoms include:
      • Abdominal pressure or cramping
      • Bloating
      • Decreased stool caliber
      • Possible obstruction
    • Less likely to have:
      • Significant abdominal tenderness
      • Guarding
      • Fever
      • Leukocytosis
  • Cause:
    • Luminal narrowing due to chronic inflammation and scarring.
  • Differential Diagnosis:
    • Must rule out malignancy.
    • Endoluminal evaluation (e.g., colonoscopy) is essential.

Complicated Diverticulitis

  • Features:
    • Presence of:
      • Abscess
      • Fistula
      • Obstruction
      • Perforation
  • Occurrence:
    • Can happen during first presentation or subsequent episodes.
  • Considerations:
    • Differential depends on specific complication.
    • All perforated viscus conditions can mimic complicated diverticulitis.
    • Assess for genitourinary issues like urinary tract infections.

Right-Sided Diverticulitis

  • Rarity:
    • Less common in North America.
  • Presentations:
    • May be asymptomatic.
    • Can present with GI bleeding or typical inflammatory symptoms.
  • Differential Diagnosis:
    • Appendicitis should be highly considered.

Key Takeaways

  • Diverticular disease ranges from asymptomatic diverticulosis to severe complications.
  • History and physical examination are critical for diagnosis.
  • Laboratory tests assist but are not definitive.
  • CT scan is the preferred imaging modality.
  • Differential diagnosis is broad due to overlapping symptoms with other conditions.
  • Classification systems help stage the disease but have limitations.
  • Patient education is important to address misconceptions and concerns.

Surgical Treatment of Diverticular Disease

Indications for Surgery

Overview

  • Surgical intervention is considered based on:
    • Type of diverticulitis: Uncomplicated vs. complicated.
    • Timing: Elective vs. emergency surgery.
  • Traditional guidelines recommended surgery after:
    • Two attacks of uncomplicated diverticulitis.
    • One attack of complicated diverticulitis.
  • Current approach is individualized, considering patient and disease factors.

Factors Influencing Surgical Decision

  • Risk of Recurrence:
    • Long segment of disease (>5 cm).
    • Positive family history.
  • Risk of Complications:
    • Immunosuppression.
    • Renal failure.
    • Collagen vascular diseases.
    • Severe findings on CT scan (e.g., abscess, extraluminal air).
  • Frequency of Attacks:
    • More than three episodes within two years.
    • Short intervals between attacks (suggesting smoldering diverticulitis).

Uncomplicated Diverticulitis

  • Elective surgery may be considered for:
    • Patients with recurrent attacks affecting quality of life.
    • High-risk individuals for complications.
  • Risk of Complicated Disease:
    • Less than 5% after an episode of uncomplicated diverticulitis.
  • Quality of Life:
    • Elective surgery has shown to improve quality of life in patients with frequent recurrent episodes.

Elective Surgery

Preoperative Considerations

  • Waiting Period:
    • Typically 4–6 weeks after acute episode for inflammation to resolve.
  • Colonic Evaluation:
    • Colonoscopy to rule out malignancy or other pathology.
  • Bowel Preparation:
    • Mechanical bowel prep with oral antibiotics reduces surgical site infections.
  • Prophylaxis:
    • Intravenous antibiotics.
    • Venous thromboembolism prophylaxis.
  • Enhanced Recovery Protocols:
    • Utilize to improve postoperative outcomes.
  • Ureteral Stents:
    • Consider in reoperative surgery or significant inflammation.

Surgical Techniques

Open Resection

  • Patient Positioning: Supine or lithotomy position.
  • Procedure Steps:
    • Midline incision and abdominal exploration.
    • Identification and preservation of ureter and gonadal vessels.
    • Resection of affected sigmoid colon.
    • Anastomosis:
      • Distal margin: Proximal rectum (taeniae splay out).
      • Proximal margin: Soft, pliable bowel (diverticula presence acceptable).
    • Splenic Flexure Mobilization:
      • Often necessary for tension-free anastomosis.
    • Anastomotic Techniques:
      • Stapled anastomosis preferred.
      • Air leak test performed to ensure integrity.

Laparoscopic Resection

  • Advantages:
    • Shorter hospital stay.
    • Faster recovery.
    • Less pain and surgical site infections.
  • Patient Positioning:
    • Split-leg table with legs abducted or modified lithotomy.
  • Procedure Steps:
    • Pneumoperitoneum established.
    • Port placement varies by surgeon preference.
    • Approaches:
      • Lateral-to-medial.
      • Medial-to-lateral.
    • Identification of Structures:
      • Inferior mesenteric artery and vein.
      • Ureter and gonadal vessels.
    • Anastomosis:
      • Similar to open technique.
      • Air leak test performed.

Robotic Resection

  • Considerations:
    • Emerging technique.
    • Potential benefits being evaluated.
    • May offer enhanced precision in dissection and suturing.

Management of Complicated Diverticulitis

Overview

  • Complicated diverticulitis includes:
    • Abscess
    • Fistula
    • Obstruction
    • Perforation
  • Goals:
    • Improve quality of life.
    • Reduce further complications.
    • Convert emergency situations into elective procedures when possible.

Diverticular Fistulas

Types

  • Colovesical Fistula (most common)
    • Symptoms: Pneumaturia, fecaluria, recurrent UTIs.
  • Colovaginal Fistula
    • Symptoms: Vaginal discharge of feces or air.
    • More common in post-hysterectomy patients.
  • Colocutaneous Fistula
    • May occur post-percutaneous drainage or due to anastomotic leaks.

Management

  • Preoperative Evaluation:
    • CT Scan: Air in bladder diagnostic for colovesical fistula.
    • Colonoscopy: Rule out malignancy.
    • Cystoscopy/Cystogram: Evaluate bladder involvement.
  • Surgical Approach:
    • Single-stage resection with primary anastomosis.
    • Fistula Management:
      • Fistula tract is excised or pinched off.
      • Omentum used for interposition if available.
      • Bladder or vaginal defects may be left to heal or sutured if accessible.
    • Postoperative Care:
      • Foley catheter drainage for bladder fistulas.
      • Cystogram prior to Foley removal.

Diverticular Strictures

  • Presentation:
    • Progressive constipation.
    • Obstructive symptoms.
  • Differential Diagnosis:
    • Must exclude malignancy via colonoscopy.
  • Management:
    • Elective Resection if partial obstruction resolves.
    • Emergency Surgery for complete obstruction:
      • Options include resection with primary anastomosis (± diversion), Hartmann procedure.

Diverticular Abscesses

Modified Hinchey Classification

  • Stage Ia: Confined pericolic inflammation (phlegmon).
  • Stage Ib: Confined pericolic or mesocolic abscess.
  • Stage II: Pelvic, distant intraabdominal, or retroperitoneal abscess.
  • Stage III: Generalized purulent peritonitis.
  • Stage IV: Fecal peritonitis.

Management

  • Small Abscesses (<4 cm):
    • Treated with intravenous antibiotics alone.
  • Large Abscesses (>4 cm):
    • Percutaneous drainage under imaging guidance.
  • Surgical Intervention:
    • Indicated if:
      • No improvement with antibiotics/drainage.
      • Signs of sepsis persist.
  • Elective Surgery Post-Recovery:
    • Considered due to higher recurrence rates.
    • Individualized based on patient factors.

Free Perforation

Hartmann Procedure

  • Traditional Approach for perforated diverticulitis.
  • Procedure:
    • Resection of diseased segment.
    • Creation of end colostomy.
    • Rectal stump closure.
  • Drawbacks:
    • High morbidity and mortality.
    • Low rates of stoma reversal (~66%).

Primary Resection with Anastomosis

  • Options:
    • With Diversion: Proximal diverting ileostomy.
    • Without Diversion: Selected cases with stable patients.
  • Advantages:
    • Avoids a permanent stoma.
    • Higher rates of stoma reversal.
  • Considerations:
    • Patient stability.
    • Degree of contamination.
    • Surgeon expertise.

Laparoscopic Lavage

  • Procedure:
    • Laparoscopic irrigation of peritoneal cavity.
    • No resection performed.
  • Indications:
    • Selected patients with purulent peritonitis (Hinchey III).
  • Evidence:
    • Recent trials show mixed results.
    • Higher rates of reoperation and postoperative abscesses.
  • Current Recommendations:
    • Not widely endorsed as standard care.
    • May be considered in specific cases.

Reoperative Surgery

Hartmann Takedown (Reversal)

  • Timing:
    • Early (<3 months) vs. late (>3 months).
  • Preoperative Evaluation:
    • Contrast Enema: Assess rectal stump and residual colon.
    • Colonoscopy: Evaluate mucosa if not previously done.
  • Surgical Approach:
    • Open or Laparoscopic depending on surgeon preference and patient factors.
    • Extensive adhesiolysis often required.
  • Anastomosis:
    • Typically performed with a circular stapler.
    • Air leak test to ensure integrity.

Postoperative Concerns

Risk of Recurrent Diverticulitis After Resection

  • Incidence:
    • Recurrent diverticulitis occurs in a small percentage of patients.
    • Higher risk if distal resection margin is not in the proximal rectum.
  • Factors Contributing to Recurrence:
    • Inadequate distal margin (residual sigmoid colon).
    • Persistent diverticula in anastomosed segments.
  • Recommendations:
    • Distal anastomosis should be to the proximal rectum (where taeniae splay out).
    • Mobilization of the splenic flexure to ensure tension-free anastomosis.

Key Takeaways

  • Surgical decisions are individualized based on patient risk factors and disease severity.
  • Elective surgery is preferred over emergency surgery when possible.
  • Laparoscopic techniques offer benefits over open surgery, including reduced recovery time.
  • Management of complications requires careful assessment and may involve percutaneous interventions or surgery.
  • Hartmann procedure has significant drawbacks; alternatives are considered based on patient stability.
  • Postoperative recurrence can be minimized with appropriate surgical margins and techniques.

Conclusion

Surgical management of diverticular disease requires a nuanced approach that considers individual patient factors, disease severity, and potential complications. Elective surgery is often successful in improving quality of life and preventing recurrent episodes. Advances in surgical techniques, particularly minimally invasive approaches, have enhanced patient outcomes. Careful preoperative planning, patient counseling, and adherence to surgical principles are essential for optimal results.