Surgical Management Of Diverticular Disease

Surgical Surgical management of management of

diverticular diseasediverticular diseaseA recent literature reviewA recent literature review

REDA SALEM HUSSEIN.FRCSROYAL SHRESBURY HOSPITALENGLAND-UK

Case presentation (1)Case presentation (1)

• 40 year old female40 year old female• PMH: PMH:

NIDDM, EpilepsyNIDDM, Epilepsy• PSH: PSH:

2003: Hysterectomy2003: HysterectomyJune 2005: Diagnostic laparoscopy June 2005: Diagnostic laparoscopy (under gynae)(under gynae)- PID (Pus in pelvis, RIF, Right paracolic - PID (Pus in pelvis, RIF, Right paracolic gutter) - Normal appendix, GB, SB, gutter) - Normal appendix, GB, SB, Sigmoid colonSigmoid colon

Case presentation (2)Case presentation (2)• PSH (cont)PSH (cont)

4th January 2006: Bilateral salpingo-oophorectomy4th January 2006: Bilateral salpingo-oophorectomy

• Findings: extensive adhesions, sigmoid colon to Findings: extensive adhesions, sigmoid colon to pelvis, tubes and ovaries. pelvis, tubes and ovaries.

Sigmoid colon: likely diverticular abscess.Sigmoid colon: likely diverticular abscess.

General surgeon called to theatre: As unlikely General surgeon called to theatre: As unlikely previous leak, no history of obstructive symptoms, previous leak, no history of obstructive symptoms, and no evidence of leak now, was treated and no evidence of leak now, was treated conservatively without resection.conservatively without resection.

• Extensive adhesionolysis and bilateral salpingo-Extensive adhesionolysis and bilateral salpingo-oophorectomy oophorectomy

Case presentation (3)Case presentation (3)• Readmitted: 21st January 2006 - generally unwell, abdominal pain, Readmitted: 21st January 2006 - generally unwell, abdominal pain,

open wound with faeculent discharge open wound with faeculent discharge

• Imp: Probable entero-cutaneous fistula Imp: Probable entero-cutaneous fistula

• Initial conservative management with IV ABX, TPN, laying open of Initial conservative management with IV ABX, TPN, laying open of infected wound.infected wound.

• 2828thth January - CT scan confirmed fistula from sigmoid colon. January - CT scan confirmed fistula from sigmoid colon.

• Initial improvement but became septic - 5th February - Hartmans Initial improvement but became septic - 5th February - Hartmans procedureprocedure

• 13/02/06 - Wound looks clean, good granulation tissue, vac 13/02/06 - Wound looks clean, good granulation tissue, vac dressingsdressings

• Discharged 22/2/6Discharged 22/2/6

Surgical management of Surgical management of diverticular diseasediverticular disease

• There is a wide clinical spectrum:There is a wide clinical spectrum:- incidental finding - incidental finding - symptomatic uncomplicated disease- symptomatic uncomplicated disease- diverticulitis- diverticulitis

• surgery is reserved for patients with surgery is reserved for patients with complications of diverticular disease complications of diverticular disease which cannot be resolved by medical which cannot be resolved by medical management.management.


Epidemiology and management of Epidemiology and management of diverticular disease of the colon.diverticular disease of the colon.

- Drugs Aging. 2004;21(4):211-28. - Drugs Aging. 2004;21(4):211-28. Review. Review.


Diverticular abscessDiverticular abscess

The following classification of diverticular The following classification of diverticular abscesses has been proposed by Hinchey et al.abscesses has been proposed by Hinchey et al.[66][66]

• Stage IStage I: small, contained pericolonic abscesses.: small, contained pericolonic abscesses.• Stage IIStage II: more distant (pelvic, intra-abdominal : more distant (pelvic, intra-abdominal

or retroperitoneal) abscesses that are still or retroperitoneal) abscesses that are still walled-off. walled-off.

• Stage III:Stage III: involves purulent peritonitis. involves purulent peritonitis.• Stage IVStage IV : indicates faeculent peritonitis : indicates faeculent peritonitis


Diverticular abscess (1)Diverticular abscess (1)

• Small <5cm abscesses may resolve with antibacterial Small <5cm abscesses may resolve with antibacterial therapytherapy

• Patients with larger abscesses or those who fail to Patients with larger abscesses or those who fail to improve with antibacterial therapy should undergo CT improve with antibacterial therapy should undergo CT guided percutaneous drainage.guided percutaneous drainage.

• If amenable, percutaneous drainage is successful in up If amenable, percutaneous drainage is successful in up to 90% of patients. to 90% of patients.

• The chance of success with non-operative therapy is The chance of success with non-operative therapy is inversely proportional to the number of drainage inversely proportional to the number of drainage catheters required.catheters required.


Diverticular abscess (2)Diverticular abscess (2)

• Operative therapy should be considered if more than two Operative therapy should be considered if more than two catheters are needed.catheters are needed.

• Not all patients who have undergone successful Not all patients who have undergone successful percutaneous abscess drainage require subsequent percutaneous abscess drainage require subsequent elective bowel resection.elective bowel resection.

• Non-operated patients should have complete colonic Non-operated patients should have complete colonic evaluation 4–6 weeks after resolution of the abscess.evaluation 4–6 weeks after resolution of the abscess.

• Colonic resection is indicated for those who develop either Colonic resection is indicated for those who develop either recurrent diverticulitis and/or another abscess.recurrent diverticulitis and/or another abscess.


IImpact of CT-guided drainage in mpact of CT-guided drainage in the treatment of diverticular the treatment of diverticular abscesses: size mattersabscesses: size matters

- AJR Am J Roentgenol 2006 - AJR Am J Roentgenol 2006


1. Patients with abscesses smaller than 3 cm in 1. Patients with abscesses smaller than 3 cm in size can be treated with antibiotics alone and, size can be treated with antibiotics alone and, in some cases, as outpatients,in some cases, as outpatients,

2. Also likely true for patients with abscesses 3-2. Also likely true for patients with abscesses 3-4 cm in size, although results limited by a 4 cm in size, although results limited by a small sample size. small sample size.

3. Patients with abscesses larger than or equal 3. Patients with abscesses larger than or equal to 4 cm can be managed with CT-guided to 4 cm can be managed with CT-guided abscess drainage followed by referral for abscess drainage followed by referral for surgical treatment. (After resolution of surgical treatment. (After resolution of symptoms, elective surgery was performed in symptoms, elective surgery was performed in five (62.5%) of eight of the larger abscesses)five (62.5%) of eight of the larger abscesses)


Obstruction/StricturesObstruction/Strictures

1. Patients who present with large bowel obstruction often 1. Patients who present with large bowel obstruction often undergo emergency surgery undergo emergency surgery

2. Recently, a more conservative approach has been explored 2. Recently, a more conservative approach has been explored - metallic stents to relieve colonic obstruction as the first - metallic stents to relieve colonic obstruction as the first stage of a curative surgical procedure or for palliation stage of a curative surgical procedure or for palliation without surgery.without surgery.

3. Endoluminal colonic wall stents shown to be safe and 3. Endoluminal colonic wall stents shown to be safe and effective in decompressing obstruction. effective in decompressing obstruction.

4. Should be considered as the initial, non operative 4. Should be considered as the initial, non operative management of selected patients with large bowel management of selected patients with large bowel obstruction in the absence of peritonitisobstruction in the absence of peritonitis


Acute diverticulitis(1)Acute diverticulitis(1)

Laparoscopic surgery:Laparoscopic surgery:• laparoscopic surgeons have turned to diverticular disease laparoscopic surgeons have turned to diverticular disease

as an area where they can perform colectomies safely.as an area where they can perform colectomies safely.• Anastomoses can be per formed in such patients using Anastomoses can be per formed in such patients using

staple guns. staple guns. • reverse Hartmann’s procedures. reverse Hartmann’s procedures.

Results Results • based on open prospective studies that are not randomised. based on open prospective studies that are not randomised. • shorter length of admissionshorter length of admission• less morbidityless morbidity• Less pain.Less pain.

However:However:• Steep learning curveSteep learning curve• Expensive equipmentExpensive equipment


• Acute diverticulitis(2)Acute diverticulitis(2)

Open surgeryOpen surgery

• no agreement as to which is the right operation. no agreement as to which is the right operation. • Studies are largely retrospective and suffer from selection Studies are largely retrospective and suffer from selection

bias.bias.• Two randomised studies came to completely different Two randomised studies came to completely different

conclusions.conclusions.

• 1. A study from Denmark (1993)1. A study from Denmark (1993)

- higher mortality in patients with purulent peritonitis (6/25) - higher mortality in patients with purulent peritonitis (6/25) after resection compared with colostomy (0/21).after resection compared with colostomy (0/21).- lower mortality in faecal peritoni-tis (2/6) after resection - lower mortality in faecal peritoni-tis (2/6) after resection compared with colostomy (6/10). compared with colostomy (6/10).

• 2. More recently a similar study from France of 105 patients 2. More recently a similar study from France of 105 patients - showed an overall mortality of 19% for a colostomy - showed an overall mortality of 19% for a colostomy compared with 24% for a primary resection. compared with 24% for a primary resection.


Surgery for Colovesical FistulaeSurgery for Colovesical Fistulae

• The simplest form of colovesical fistula is a mobile The simplest form of colovesical fistula is a mobile loop of sigmoid colon stuck onto the dome of the loop of sigmoid colon stuck onto the dome of the bladderbladder

• some have advocated treatment with out bowel some have advocated treatment with out bowel resection by closing the fistula and inter posing resection by closing the fistula and inter posing omentum between the bowel and the bladderomentum between the bowel and the bladder

- and this conservative approach was reported to - and this conservative approach was reported to be safe in all but one patient in a published series.be safe in all but one patient in a published series.

• conventionally a bowel resection is performed conventionally a bowel resection is performed with end to end primary anastomosiswith end to end primary anastomosis- bladder hole is left open - bladder hole is left open - urethral catheter is left in place on free drainage - urethral catheter is left in place on free drainage for 2/52for 2/52


Diverticulitis in the youngDiverticulitis in the young- Dis Colon Rectum. 2004 Jul;47Dis Colon Rectum. 2004 Jul;47

- ““Diverticulitis has been described as Diverticulitis has been described as a more virulent disease in young a more virulent disease in young patients, necessitating an aggressive patients, necessitating an aggressive surgical approach.”surgical approach.”

• RESULTS: RESULTS:

• A total of 762 patients were admitted with sigmoid A total of 762 patients were admitted with sigmoid diverticulitis during the study perioddiverticulitis during the study period

• Two hundred fifty-nine patients (34 percent) were younger Two hundred fifty-nine patients (34 percent) were younger than aged 50 years (Group 1). Group 2 > 50 years ld (66 than aged 50 years (Group 1). Group 2 > 50 years ld (66 percent)percent)

• The risk of requiring surgery on initial hospital The risk of requiring surgery on initial hospital presentation was similar between the two groups (24 vs. presentation was similar between the two groups (24 vs. 22 percent, respectively). 22 percent, respectively).

• However, Group 1 patients were more likely to be treated However, Group 1 patients were more likely to be treated operatively at some point during the study period (40 vs. operatively at some point during the study period (40 vs. 26 percent; P = 0.001) because of an increase in elective 26 percent; P = 0.001) because of an increase in elective resections.resections.

• Of 196 patients in Group 1 who had an initial medically Of 196 patients in Group 1 who had an initial medically managed admission, only 1 presented at a later date with managed admission, only 1 presented at a later date with perforation (0.5 percent). perforation (0.5 percent).

• CONCLUSIONS: CONCLUSIONS:

• The risk of subsequent diverticular The risk of subsequent diverticular perforation in medically managed young perforation in medically managed young patients with sigmoid diverticulitis is very patients with sigmoid diverticulitis is very low.low.

• As such, the frequently espoused policy As such, the frequently espoused policy of routine surgery after a single attack of of routine surgery after a single attack of diverticulitis in young patients may not be diverticulitis in young patients may not be warranted. warranted.

• A more selective approach seems to be A more selective approach seems to be safe.safe.

Surgical Management Of Diverticular Disease

Health & Medicine

sigmoid colon

likely diverticular

medical management

sigmoid diverticulitis

case presentation

managed young patients

initial hospital presentation

stage iv