Management of perforative diverticulitis

Meta-analysis of surgical strategies in perforated left colonic diverticulitis with generalized peritonitis

PURPOSE

Surgical strategies for perforated diverticulitis (Hinchey stages III and IV) remain controversial. This systematic review aimed to compare the outcome of primary anastomosis, Hartmann procedure and laparoscopic lavage.

METHODS

A systematic literature search was conducted through Medline, Embase, Cochrane Central Register and Health Technology Assessment Database to identify randomized and non-randomized controlled trials involving patients with perforated left-sided colonic diverticulitis comparing different surgical strategies. The methodological quality of the included studies was assessed systematically (Grading of Recommendations, Assessment, Development and Evaluation) and a meta-analysis was performed.

RESULTS

After screening 4090 titles and abstracts published between 1958 and January 2018, 148 were selected for full text assessment. Sixteen trials (7 RCTs, 9 non-RCTs) with 1223 patients were included. Mortality rates were not significantly different between Hartmann procedure and primary anastomosis for Hinchey III and IV, neither in the meta-analysis of three RCTs (RR 2.03 (95% CI 0.79 to 5.25); p = 0.14, moderate quality of evidence) nor in the meta-analysis of six observational studies (RR 1.53 (95% CI 0.89 to 2.65); p = 0.13, very low quality of evidence). However, stoma reversal rates were significantly higher in the primary anastomosis group (RR 0.73 (95% CI 0.58 to 0.98); p = 0.008, moderate quality of evidence). Meta-analysis of four RCTs showed no significant difference between laparoscopic lavage for Hinchey III compared to sigmoid resection neither for mortality (RR 1.07 (95% CI 0.65 to 1.76); p = 0.79, moderate quality of evidence) nor for major complications (RR 0.86 (95% CI 0.69 to 1.08); p = 0.20, moderate quality of evidence).

CONCLUSIONS

This systematic review suggests similar rates of complications but higher rates of colonic restoration after primary anastomosis compared to Hartmann procedure in perforated diverticulitis with generalized peritonitis (Hinchey III and IV). Results in laparoscopic lavage for Hinchey III are not superior to primary resection. However, further studies with a careful interpretation of the meaning of re-interventions are required.

Surgical outcomes and prognostic factors of emergency surgery for colonic perforation: would fecal contamination increase morbidity and mortality?

PURPOSE

Complications resulting from colonic perforation are related to secondary peritonitis due to bacterial or fecal contamination. We investigated outcomes of emergency surgery for colonic perforation associated with fecal contamination with regard to early and late postoperative complication rates and mortality rates, and investigated prognostic factors influencing those outcomes.

METHODS

A retrospective analysis of prospectively collected data on factors influencing complications and mortality rates was conducted on data from 152 patients who had undergone emergent operations for colonic perforation between January 2005 and December 2011. Patients were categorized into two groups: those with and without gross fecal contamination at the time of operation.

RESULTS

Forty-one (26.9 %) patients had gross fecal contamination. Patients who had fetal contamination had a higher Mannheim peritonitis index (31.3 ± 5.1 vs. 21.9 ± 7.2, p < 0.001), higher organ failure rate (53.7 vs. 24.3 %, p = 0.001), and longer operating time (168.8 ± 49.9 vs. 144.8 ± 66.1 min, p = 0.036) than patients without fecal contamination. Early complications (<30 days) occurred more frequently in the fecal contamination group (82.9 vs. 49.5 %, p = 0.001), although late complications (46.2 vs. 39.3 %, p = 0.942) and mortality (17.1 vs. 8.1 %, p = 0.110) did not differ. In multivariate analysis, fecal contamination significantly predicted early complications (odds ratio, 2.78; p = 0.037) but not late complications or mortality.

CONCLUSIONS

The frequency of early complications can increase if fecal contamination exists. However, when early complications are well managed, fecal contamination does not significantly influence occurrences late complications or mortality.

Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis

BACKGROUND

This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.

OBJECTIVE

This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.

METHODS

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.

RESULTS

Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).

CONCLUSIONS

Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

Sigmoid diverticulitis in 2011: many questions; few answers

AIM

Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery.

METHOD

Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles.

RESULTS

Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence.

CONCLUSION

CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.

The surgeon's view

Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.

Damage control strategy for the management of perforated diverticulitis with generalized peritonitis: laparoscopic lavage and drainage vs. laparoscopic Hartmann's procedure

BACKGROUND

This study was designed to compare laparoscopic peritoneal lavage and drainage (LLD) with laparoscopic Hartmann's procedure (LHP) in the management of perforated diverticulitis and to investigate a safer and more effective laparoscopic method for managing acute perforated diverticulitis with generalized peritonitis.

METHODS

A consecutive series of patients who underwent emergent LHP or LLD for perforated diverticulitis were identified from a prospectively designed database. All procedure-related information was collected and analyzed. P < 5 % was considered statistically significant in this study.

RESULTS

A total of 88 patients underwent emergent laparoscopic procedures (47 LLD and 41 LHP) between 1995 and 2010 for acute perforated diverticulitis. Diagnostic laparoscopy classified 74 (84.1 %) patients as Hinchey III or IV perforated diverticulitis. OT for LHP was 182 ± 54.7 min, and EBL was 210 ± 170.5 ml. Six LHP (14.6 %) were converted to open Hartmann's for various reasons. Moreover the rates of LHP-associated postoperative mortality and morbidity were 2.4 and 17.1 %, respectively. For LLD, the operating time was 99.7 ± 39.8 min, and blood loss was 34.4 ± 21.2 ml. Three patients (6.4 %) were reoperated for the worsening of septic symptoms during post-LLD course. Moreover, the patients with LHP had significantly longer hospital stay than the ones with LLD did (16.3 ± 10.1 vs. 6.7 ± 2.2 days, P < 0.01). In the long-term follow-up, the rate of colostomy closure for LHP is 72.2 %, and 21 of 47 patients who underwent LLD had elective sigmoidectomy for the source control with the rate of 44.7 %.

CONCLUSIONS

Both LHP and LLD can be performed safely and effectively for managing severe diverticulitis with generalized peritonitis. Compared with LHP, LLD does not remove the pathogenic source; however, the clinical application of this damage control operation to our patients showed significantly better short- and long-term clinical outcomes for managing perforated diverticulitis with various Hinchey classifications.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures

OBJECTIVE

To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis.

SUMMARY BACKGROUND DATA

The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure.

METHODS

Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed.

RESULTS

A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively.

CONCLUSION

Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

Perforated diverticulitis managed by laparoscopic lavage

BACKGROUND

Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann's procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy. We present our early experience in managing perforated diverticulitis acutely by laparoscopic lavage and drainage.

METHODS

A retrospective review was conducted of all patients with surgically confirmed perforated diverticulitis. Details concerning the nature of presentation, operative findings, postoperative course and medium-term progress were investigated.

RESULTS

Fourteen patients with a mean age of 57.2 years were identified over a 3-year period. All patients presented with peritonitis and systemic sepsis. Ten patients had extraluminal gas on preoperative imaging. Laparoscopic lavage and drainage, without resection or stoma, was the initial management in all cases. Sigmoid diverticulitis was confirmed in all cases, complicated by Hinchey grade 3 purulent peritonitis in 10 patients, grade 2 contamination in 2 patients and grade 4 faeculent peritonitis in 2 patients. Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5-32 days). Three patients did not improve and underwent acute resection. Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks, which was carried out laparoscopically in all but one case.

CONCLUSION

Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis may be a promising alternative to more radical procedures, including the Hartmann's procedure. Acute resection should still be carried out in patients found to have faecal peritonitis or who fail to improve following lavage.

Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases

PURPOSE

The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon.

METHODS

Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months.

RESULTS

of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09).

CONCLUSIONS

Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review

PURPOSE

This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis.

METHODS

This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity.

RESULTS

Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent.

CONCLUSIONS

Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.

Diverticulitis: when and how to operate?

Diverticular disease, and particularly diverticulitis, has increasing incidence in industrialised countries. Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease. Conservative or medical management is usually indicated for acute uncomplicated diverticulitis. Indications for surgery include recurrent attacks and complications of the disease. Surgical treatment options have changed considerably over the years along with the inventions of new diagnostic tools and new surgical therapeutic approaches. Indications and timing for surgery of diverticular disease are determined mainly by the stage of the disease. In addition to this major factor, the individual risk factors of the patient along with the course of the disease after conservative or operative therapy do play a big role in decision-making and treatment of this disease. In this context, the purpose of this article is to review the surgical treatment of diverticulitis with regard to indications, timeliness of operative intervention, operative options and techniques, and special circumstances.

Diverticulitis

Although diverticular disease is common in the Western world, few patients who develop diverticulitis require surgery. The use of appropriate broad-spectrum antibiotics in uncomplicated diverticulitis can be an effective treatment, avoiding the need for acute surgical intervention. In the event of surgery the choice of procedure is dictated by the degree of contamination and the expertise of the operating surgeon. This chapter will outline the modern management of diverticulitis, from steps in diagnosis to different surgical options in each clinical scenario, thus aiding clinicians on a practical level.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease

BACKGROUND

Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.

METHODS

One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted.

RESULTS

Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence.

CONCLUSION

Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease

BACKGROUND

A primary anastomosis after resection of the sigmoid colon for suspected acute complicated diverticular disease has the advantage of saving the patient a secondary operation for restoring bowel continuity. Fear of anastomotic leakage often deters surgeons from making a primary anastomosis.

METHODS

A series of 45 patients who underwent primary anastomosis was studied prospectively to evaluate the feasibility of a primary anastomosis following acute sigmoid resection. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mannheim Peritonitis Index (MPI) and Hughes' peritonitis classification were used to classify patients and to detect factors predictive of postoperative outcome. Death, anastomotic leakage and septic complications were main outcome measures.

RESULTS

Neither anastomotic leakage (four of 45 patients) nor death (three of 45) was related to a higher MPI, APACHE II or Hughes' score. More postoperative septic complications were seen in patients with a MPI over 16. Death, anastomotic leakage, reintervention and wound infection were observed more frequently in patients who presented with colonic obstruction than in those with abscess or perforation.

CONCLUSION

Primary anastomosis is safe and effective in non-obstructed cases of complicated diverticular disease. Colonic obstruction seems to be a risk factor for the development of postoperative complications.

Acute diverticulitis in young adults

Diverticular disease of the colon is generally considered a disease of older patients, rarely causing symptoms before age 40. Two recent cases of ruptured sigmoid diverticulitis in young female patients presenting to our Emergency Department prompted a review of the literature on this topic. Diverticulitis is more common in patients under 40 than previously suspected. Presented are the two cases and a brief summary of the literature review.

National audit of complicated diverticular disease: analysis of index cases

Details of 300 patients with complicated diverticular disease from 30 hospitals between 1985 and 1988 were entered into a national audit organized by the Surgical Research Society. Complications present on admission included acute phlegmon (n = 104), pericolic abscess (n = 34), purulent peritonitis (n = 40), large bowel obstruction (n = 31), faecal peritonitis (n = 23), pericolic abscess complicated by fistula (n = 28) and lower gastrointestinal bleeding (n = 40). The overall mortality rate was 11.3 per cent (acute phlegmon, 4 per cent; purulent peritonitis, 27 per cent; pericolic abscess, 12 per cent; faecal peritonitis, 48 per cent; large bowel obstruction, 6 per cent; bleeding, 2 per cent; fistula, 4 per cent). Acute phlegmon was treated without operation in 78 patients (75.0 per cent) and by resection in 24 (23.1 per cent). Management of purulent peritonitis generally involved Hartmann's procedure (62 per cent) or resection and primary anastomosis (15 per cent). Similarly, patients with pericolic abscess usually underwent Hartmann's procedure (38 per cent) or resection and primary anastomosis (35 per cent). The principal operation for faecal peritonitis was Hartmann's resection (83 per cent). Large bowel obstruction was managed conservatively in four patients (13 per cent), by Hartmann's procedure in nine (29 per cent), and by resection and primary anastomosis with or without a proximal stoma in 13 (42 per cent). Most patients (82 per cent) with fistula associated with an abscess were managed by resection and primary anastomosis; 90 per cent with acute gastrointestinal bleeding were treated without operation.

Surgery for complicated diverticulitis

The surgical treatment of acute, complicated diverticulitis remains controversial. No randomized studies have been performed to clarify which operative procedure best fits each situation. As a result, the surgeon must use accumulated knowledge and judgment to make the correct decisions for an individual patient. The morbidity and mortality of patients with complicated diverticular disease in 1993 depend, not so much on the operative procedure, but on the severity of the disease and the associated comorbid conditions, namely the presence of fecal or purulent peritonitis, past medical problems, immune status, and nutritional status. However, adherence to the several principles detailed in this report will minimize morbidity and mortality. The surgeon should always attempt to convert the patient from an emergency to an urgent or elective operative status. In the absence of free perforation, this goal usually can be achieved. Rushing into surgery in patients with a normal immune system is generally ill advised. It is far preferable to stabilize the patient, percutaneously drain abscesses if possible, prepare the bowel before exploration, and thus keep the option of primary anastomosis open. A primary anastomosis done first thing in the morning is far preferable to an end-stoma created in the middle of the night in an emergency situation. The algorithm displayed in Figure 1 provides a useful guideline for treating patients with complicated diverticulitis.

Complication of the intracolonic bypass. Report of a case

The intracolonic bypass has been used both experimentally and clinically to avoid high-risk primary colonic anastomosis in the face of peritonitis. Experimental and clinical data have established the Coloshield as safe, with few clinical complications reported. This is a review of the literature and a case report of a complication of an intracolonic bypass that was found to have eroded through the colon in the early postoperative period.

Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis. A prospective study of 140 patients

In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10-47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary, en bloc resection with immediate anastomosis can usually be safely performed. Pelvic and intraabdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.

Prognostic factors from computed tomography in acute left colonic diverticulitis

This prospective study examined factors which may predict a poor outcome (complications and recurrence) after a first attack of diverticulitis which has been successfully managed conservatively. Twenty-four of 107 patients who entered the study had a poor outcome: persistent diverticulitis (nine cases), recurrence (seven cases), colonic stenosis (six cases), residual parasigmoid abscess (one case) and colovesical fistula (one case). Eight of the 18 men aged 50 years or less had a poor outcome compared with 16 of the remaining 89 patients (P = 0.032). Twelve of 76 patients (16 per cent) with mild findings on computed tomography (CT) (localized thickening of colonic wall and inflammation of pericolic fat) had a poor outcome compared with 11 of 23 patients (48 per cent) whose CT was estimated as severe (abscess and/or extraluminal air and/or extraluminal Gastrografin) (P = 0.004). These results suggest that elective colectomy can be proposed after a first attack of acute left diverticulitis in men up to 50 years of age and/or in patients whose initial CT reveals findings of severe diverticulitis.

Preoperative percutaneous drainage of diverticular abscesses

To define the role of percutaneous catheter drainage in the initial management of diverticular abscess, we reviewed 19 patients who were followed for an average of 17.4 months after drainage. All patients had large paracolic or pelvic abscesses with a mean size of 8.9 cm. There were no complications related to catheter placement, and 15 patients (79 percent) required drainage for less than 3 weeks. Sepsis resolved rapidly, and only two patients (11 percent) had persistent fever or leukocytosis beyond the third day of drainage. Routine sinography revealed fistulous communications to the colon in nine patients (47 percent), but only three (16 percent) had grossly feculent drainage. Fourteen patients (74 percent) completed the treatment plan of preoperative catheter drainage followed by single-stage sigmoid colectomy and primary anastomosis without complications. Two patients refused operation, one of whom died 16 days postoperatively from recurrent sepsis and end-stage pulmonary disease. The three patients with fecal fistulas all had inadequate control of infection, suggesting the need for early operation and fecal diversion in such cases. We conclude that preoperative percutaneous catheter drainage obviates the need for colostomy and multiple-stage surgery in approximately three-fourths of patients with large diverticular abscesses.

Primary resection and anastomosis for treatment of acute diverticulitis

The patterns of presentation and associated treatments of 65 patients with acute perforated diverticulitis of the left colon have been reviewed. Four types of operations were identified: primary resection with anastomosis (group I, N = 29), primary resection with anastomosis and protective colostomy (group II, N = 5), primary resection with Hartmann procedure (group III, N = 26), and delayed resection three-staged procedure (group IV, N = 5). The severity of disease was also classified (stages I to IV). Postoperative mortality rates in the first two groups were lower than that of the Hartmann group (3.4 vs. 15.3 percent). The mean length of initial hospitalization was 16 +/- 1.2 days for group I, 18.2 +/- 4.4 days for group II, 19.4 +/- 2 days for group III, 26.4 +/- 4.4 days for group IV (P less than .05, t-test group IV vs. groups I, II, and III). Complications in the Hartmann group were high with a 23 percent wound infection rate and mortality after closure of colostomy and bowel reconstruction was 3.8 percent. These data demonstrate that primary resection with anastomosis is a satisfactory operation for the majority of patients with perforated diverticulitis (stages I to III), and there appears to be no clinical indication to use the three-staged operation.

Diverticular disease

Although most often clinically silent, colonic diverticula are responsible for a large number of gastrointestinal illnesses in our society. Complications of diverticular disease, including perforation and hemorrhage, may occur in 15% to 20% of patients with diverticula during their lifetime, and although often mild and self-limiting diseases, they too frequently cause life-threatening problems that require prompt surgical intervention. Despite a cadre of sophisticated laboratory and radiologic tests that have been developed to aid in the diagnosis of complicated diverticular disease, the diagnosis and treatment of diverticulitis still relies heavily on patient history, physical examination, physician judgment, and the patient's clinical response to treatment. Thus it is important for the managing physician to fully understand the pathogenesis of diverticula, the clinical consequences and modes of presentation of complicated diverticular disease, and the array of interventions available for treatment of these problems. This monograph summarizes our knowledge of diverticular disease to date and tries to give specific guidelines for the treatment of patients with complicated diverticulitis. However, it must be understood that the presentation and severity of these complications vary widely from patient to patient. Thus one cannot take a single approach toward a patient who has diverticulitis or diverticular bleeding. Rather, successful outcomes depend on an individual approach to each patient while maintaining certain generally accepted principles of treatment.

Colorectal anastomotic healing and intracolonic bypass procedure

Intestinal anastomoses continue to be complicated by leakages even in the best of hands despite the development of new surgical techniques, suture materials, devices, and stapling instruments. One may explain such persistence of anastomotic leakage on the basis of the dynamic effect that multiple factors have on the healing of an anastomosis. Awareness of these factors and proper precautions by the surgeon can make a high-risk anastomosis less prone to leakage. The intracolonic bypass procedure is an alternative to a temporary colostomy. It does not prevent an anastomotic dehiscence but can prevent anastomotic leakage with its associated complications in those situations where dehiscence is most likely to occur.

Diverticular disease in Auckland

A retrospective study is presented of 200 cases of diverticular disease admitted to Auckland Hospital over the 6-year period 1979-84. The epidemiology of the total group, the mode or type of presentation, pathology and investigative practice have been examined. Seventy-six patients required surgical intervention either electively or as an emergency and these cases have been considered in detail. The surgical group included 44 men and 32 women; 21 patients presented for elective resection, and 55 patients underwent surgery during their emergency admission. In the emergency group, 20 laparotomies were performed for pericolic/pelvic abscesses, five for small/large bowel obstruction, 30 for peritonitis and only one laparotomy was performed for haemorrhage. The mortality for the entire group was 4% with all deaths occurring in the acute diverticulitis group. Three deaths followed emergency surgery and a further five patients died without coming to surgery, the diagnosis of acute diverticulitis being made only at post-mortem. Overall, 44% of cases of acute diverticulitis underwent emergency surgery and a further 6% required surgery over the next 1-5 years. Resectional surgery was practised widely in the emergency group (the most common being Hartmann's operation). Less radical surgery is also preferred for localized sepsis in selected cases. The mortality was confined to patients who did not undergo resection of the septic focus. The elective group (24 patients) usually presented as a result of stricture, or chronic symptoms, and these patients generally did well with elective resection. The group of patients presenting with colonic bleeding behaved in a very benign manner. There was no mortality and only one patient required emergency surgery for bleeding.

Acute colonic diverticulitis

Colonic diverticulosis is truly a disease of the 20th century. A direct correlation is thought to exist between the incidence of diverticular disease and the amount of dietary fiber. Acute colonic diverticulitis occurs in approximately 25 per cent of the patients with diverticula, and 20 per cent of the patients with diverticulitis will ultimately require surgical intervention. Because of the often virulent nature of the disease in younger patients and the prevalence in the geriatric population, an aggressive approach is advocated. Primary resection of the involved segment of colon is advocated in all cases requiring operation. A primary anastomosis can be constructed in stage I and some cases of stage II disease. This results in lower morbidity and mortality rates as well as fewer days of hospitalization and disability. Newer techniques such as diagnostic CT scanning, percutaneous drainage of diverticular abscess, and greater application of surgical stapling devices have done much to improve the ultimate outcome of colonic diverticulitis.

The Hartmann procedure. Extended indications in severe intra-abdominal infection

During a three-year period, 30 patients had emergency Hartmann procedures for diverticular disease (N = 12), carcinoma (N = 6), trauma (N = 3), and miscellaneous causes (N = 9). Two patients died postoperatively (6.7 percent) and wound infection developed in 60 percent of the patients. Planned relaparotomies for severe intra-abdominal infection were performed in ten patients (an average of 2.5 procedures per patient) with no mortality. In five cases a mucous fistula was converted into a Hartmann pouch; a preference for the Hartmann pouch in patients undergoing repeated explorations is discussed. Colorectal continuity was subsequently restored in 23 patients (76.6 percent).

A comparison of emergency resection and staged management in perforated diverticular disease

This retrospective view examines the outcome of surgical treatment of perforated diverticular disease in one hospital in the period 1976 to 1983. Of the 78 patients, 38 underwent emergency colonic resection (group A) whereas 40 (group b) were treated by proximal colostomy and drainage (37 patients) or suture of the perforation with drainage (three patients). There was no significant difference between groups A and B in terms of operative mortality (21 percent vs. 24 percent, respectively). Mortality rates were highest in patients with generalized peritonitis treated by colostomy and drainage (36 percent), whereas those with localized disease undergoing resection had a mortality rate of 17 percent (P less than .05). Eight of the 40 patients in group B developed fistulas whereas none of the group A patients had this complication. Only four (16 percent) of the surviving group A patients were left with a permanent colostomy as opposed to 15 (56 percent) of their counterparts in group B. In the presence of perforated diverticular disease, emergency resection carries a lower morbidity than colostomy and drainage, although the present review shows no statistically significant differences in terms of mortality.

The utility of computed tomography in colonic diverticulitis

Forty-one patients admitted to our hospital during an 18-month period with the clinical diagnosis of colonic diverticulitis were analyzed to evaluate the utility of computed tomography (CT). Abdominal pain and leukocytosis were the most common presenting manifestations, 75 and 66%, respectively. Just over one-half of the patients also demonstrated hematuria. Twenty patients required surgical intervention, most commonly for failure to improve despite medical management. Preoperative studies included 10 sigmoidoscopies, 30 plain abdominal roentgenograms, 20 barium enemas (BE), and 24 CT scans. Two CT scans were also obtained after operation for successful percutaneous drainage of intra-abdominal abscesses. Abdominal roentgenograms were most commonly obtained but least helpful, with only one third demonstrating any abnormality whatsoever. Sigmoidoscopy was least commonly performed but almost universally abnormal. Specificity was low, however, in that spasm with inability to advance the endoscope was the most common finding. Of the 20 barium enemas obtained, 60% had findings consistent with diverticulitis, most commonly localized perforation or fixed narrow segment. Sixty-three per cent of CT scans were abnormal. The most frequent findings were localized thickening of the colonic wall and increased density in the pericolic fat. Diverticular abscess, which may be inferred by other studies, was definitely diagnosed in one third of the patients with abnormal CT scans. CT also provided the ability to identify extracolonic intra-abdominal pathology. The study demonstrates that both barium enema and CT are effective in diagnosing diverticulitis, although CT can be performed without risk. CT played no therapeutic role before operation, although two patients benefited after operation by CT-guided drainage of intra-abdominal abscesses. The decision for surgery was most frequently dependent on clinical examination and never solely on the basis of either the barium enema or CT in this study. The major benefit of CT appears to be its ability to identify both gross and subtle changes indicative of diverticular disease and extracolonic pathology in a relatively noninvasive manner.

Management of the septic complications of diverticular disease

One hundred and five patients underwent surgical treatment of septic complications of diverticular disease. In nine cases, operation was carried out for acute large bowel obstruction and in the remainder for peritonitis. An inflammatory mass and/or localized abscess was found in 23 cases. Free pus without evidence of 'communicating' perforation was found in a further 33 and 'communicating' perforation in 40. Treatment by primary resection or by transverse colostomy and drainage were both associated with significantly lower mortality from sepsis than treatment by drainage alone. In cases without 'communicating' perforation, there was no difference in mortality between primary resection and transverse colostomy with drainage. Although the advantage of primary resection was most apparent in cases with 'communicating' perforation, it did not reach statistical significance. In three cases treated primarily without resection the pathology was subsequently found to be that of carcinoma. In 'favourable' circumstances, i.e. without 'communicating' perforation, defunctioning colostomy with drainage has an acceptably low mortality rate and may be undertaken by a less experienced surgeon to avoid a difficult resection. Ideally these problems should be dealt with by an experienced surgeon; we prefer to treat the septic complications of diverticular disease by primary resection.

Intra-operative colonic irrigation in the management of left-sided large bowel emergencies

In a consecutive series of 93 patients who required emergency surgery for distal colonic lesions, 61 had primary bowel resection with immediate anastomosis after intra-operative antegrade colonic irrigation. The operative mortality was 8 per cent, anastomotic leakage rate 7 per cent and superficial wound infection occurred in 3 per cent of patients. The mean hospital stay was 13 days. Of the remaining 32 patients, 3 did not have a resection and 29 had a primary resection and end colostomy without anastomosis: bowel continuity was later restored in 17 of 28 survivors (61 per cent) but 11 (39 per cent) were left with a permanent colostomy. The hospital mortality in this group was 6 per cent, superficial wound infection rate 14 per cent and the mean hospital stay 26 days. The results of this study suggest that intra-operative colonic irrigation is an effective method enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.

Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review

There is little uniformity in either the indications for operation, the classification of the pathology or the operative management of generalized or faecal peritonitis secondary to perforated diverticular disease. Nevertheless, this review has shown a clear advantage both in terms of immediate mortality and morbidity for primary resection over conservative operations in which the colon is retained in the abdomen. We propose that, when a clinical diagnosis of localized sepsis secondary to diverticular disease is made, the management should be nonoperative with systemic antibiotics and supportive therapy. Operation should be reserved for those patients with obvious generalized peritonitis or failure of conservative treatment. When operation is necessary the affected sigmoid loop should be resected and the operation completed as a Hartmann's procedure in all but the most favourable circumstances when a primary anastomosis may be considered after on-table irrigation of the colon.