Surgical Management Of Diverticular Disease


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Surgical Management Of Diverticular Disease

  1. 1. Surgical management of diverticular disease A recent literature review REDA SALEM HUSSEIN.FRCS ROYAL SHRESBURY HOSPITAL ENGLAND-UK
  2. 2. Case presentation (1) • 40 year old female • PMH: NIDDM, Epilepsy • PSH: 2003: Hysterectomy June 2005: Diagnostic laparoscopy (under gynae) - PID (Pus in pelvis, RIF, Right paracolic gutter) - Normal appendix, GB, SB, Sigmoid colon
  3. 3. Case presentation (2) • PSH (cont) 4th January 2006: Bilateral salpingo-oophorectomy • Findings: extensive adhesions, sigmoid colon to pelvis, tubes and ovaries. Sigmoid colon: likely diverticular abscess. General surgeon called to theatre: As unlikely previous leak, no history of obstructive symptoms, and no evidence of leak now, was treated conservatively without resection. • Extensive adhesionolysis and bilateral salpingo-oophorectomy
  4. 4. Case presentation (3) • Readmitted: 21st January 2006 - generally unwell, abdominal pain, open wound with faeculent discharge • Imp: Probable entero-cutaneous fistula • Initial conservative management with IV ABX, TPN, laying open of infected wound. • 28th January - CT scan confirmed fistula from sigmoid colon. • Initial improvement but became septic - 5th February - Hartmans procedure • 13/02/06 - Wound looks clean, good granulation tissue, vac dressings • Discharged 22/2/6
  5. 5. Surgical management of diverticular disease • There is a wide clinical spectrum: - incidental finding - symptomatic uncomplicated disease - diverticulitis • surgery is reserved for patients with complications of diverticular disease which cannot be resolved by medical management.
  6. 6. Surgical management of diverticular disease Epidemiology and management of diverticular disease of the colon. - Drugs Aging. 2004;21(4):211-28. Review.
  7. 7. Surgical management of diverticular disease Diverticular abscess The following classification of diverticular abscesses has been proposed by Hinchey et al.[66] • Stage I: small, contained pericolonic abscesses. • Stage II: more distant (pelvic, intra-abdominal or retroperitoneal) abscesses that are still walled-off. • Stage III: involves purulent peritonitis. • Stage IV : indicates faeculent peritonitis
  8. 8. Surgical management of diverticular disease Diverticular abscess (1) • Small <5cm abscesses may resolve with antibacterial therapy • Patients with larger abscesses or those who fail to improve with antibacterial therapy should undergo CT guided percutaneous drainage. • If amenable, percutaneous drainage is successful in up to 90% of patients. • The chance of success with non-operative therapy is inversely proportional to the number of drainage catheters required.
  9. 9. Surgical management of diverticular disease Diverticular abscess (2) • Operative therapy should be considered if more than two catheters are needed. • Not all patients who have undergone successful percutaneous abscess drainage require subsequent elective bowel resection. • Non-operated patients should have complete colonic evaluation 4–6 weeks after resolution of the abscess. • Colonic resection is indicated for those who develop either recurrent diverticulitis and/or another abscess.
  10. 10. Surgical management of diverticular disease Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters - AJR Am J Roentgenol 2006
  11. 11. Surgical management of diverticular disease 1. Patients with abscesses smaller than 3 cm in size can be treated with antibiotics alone and, in some cases, as outpatients, 2. Also likely true for patients with abscesses 3-4 cm in size, although results limited by a small sample size. 3. Patients with abscesses larger than or equal to 4 cm can be managed with CT-guided abscess drainage followed by referral for surgical treatment. (After resolution of symptoms, elective surgery was performed in five (62.5%) of eight of the larger abscesses)
  12. 12. Surgical management of diverticular disease Obstruction/Strictures 1. Patients who present with large bowel obstruction often undergo emergency surgery 2. Recently, a more conservative approach has been explored - metallic stents to relieve colonic obstruction as the first stage of a curative surgical procedure or for palliation without surgery. 3. Endoluminal colonic wall stents shown to be safe and effective in decompressing obstruction. 4. Should be considered as the initial, non operative management of selected patients with large bowel obstruction in the absence of peritonitis
  13. 13. Surgical management of diverticular disease Acute diverticulitis(1) Laparoscopic surgery: • laparoscopic surgeons have turned to diverticular disease as an area where they can perform colectomies safely. • Anastomoses can be per formed in such patients using staple guns. • reverse Hartmann’s procedures. Results • based on open prospective studies that are not randomised. • shorter length of admission • less morbidity • Less pain. However: • Steep learning curve • Expensive equipment
  14. 14. Surgical management of diverticular disease • Acute diverticulitis(2) Open surgery • no agreement as to which is the right operation. • Studies are largely retrospective and suffer from selection bias. • Two randomised studies came to completely different conclusions. • 1. A study from Denmark (1993) - higher mortality in patients with purulent peritonitis (6/25) after resection compared with colostomy (0/21). - lower mortality in faecal peritoni-tis (2/6) after resection compared with colostomy (6/10). • 2. More recently a similar study from France of 105 patients - showed an overall mortality of 19% for a colostomy compared with 24% for a primary resection.
  15. 15. Surgical management of diverticular disease Surgery for Colovesical Fistulae • The simplest form of colovesical fistula is a mobile loop of sigmoid colon stuck onto the dome of the bladder • some have advocated treatment with out bowel resection by closing the fistula and inter posing omentum between the bowel and the bladder - and this conservative approach was reported to be safe in all but one patient in a published series. • conventionally a bowel resection is performed with end to end primary anastomosis - bladder hole is left open - urethral catheter is left in place on free drainage for 2/52
  16. 16. Surgical management of diverticular disease Diverticulitis in the young - Dis Colon Rectum. 2004 Jul;47 - “Diverticulitis has been described as a more virulent disease in young patients, necessitating an aggressive surgical approach.”
  17. 17. • RESULTS: • A total of 762 patients were admitted with sigmoid diverticulitis during the study period • Two hundred fifty-nine patients (34 percent) were younger than aged 50 years (Group 1). Group 2 > 50 years ld (66 percent) • The risk of requiring surgery on initial hospital presentation was similar between the two groups (24 vs. 22 percent, respectively). • However, Group 1 patients were more likely to be treated operatively at some point during the study period (40 vs. 26 percent; P = 0.001) because of an increase in elective resections. • Of 196 patients in Group 1 who had an initial medically managed admission, only 1 presented at a later date with perforation (0.5 percent).
  18. 18. • CONCLUSIONS: • The risk of subsequent diverticular perforation in medically managed young patients with sigmoid diverticulitis is very low. • As such, the frequently espoused policy of routine surgery after a single attack of diverticulitis in young patients may not be warranted. • A more selective approach seems to be safe.