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New Paradigms in the Management of Diverticular Disease

A colonic diverticulum is a saccular outpouching of the colonic wall. Diverticula may be false, containing mucosa and muscularis mucosa, or true, containing all layers of the bowel wall. Although the terms diverticulosis, diverticulitis, and diverticular disease are often used interchangeably, in this monograph, diverticulosis refers to the presence of diverticula within the colon in the absence of inammation. Diverticulitis refers to the presence of peridiverticular inammation and infection and diverticular disease refers to the range of problems that may be caused by diverticula. Diverticular disease represents a wide spectrum of conditions ranging from mild left lower quadrant pain and bloating to free perforation with peritonitis and sepsis. These presentations have typically been classied into complicated or uncomplicated disease. Complicated presentations of diverticular disease refer specically to episodes of perforation, obstruction, stricture, stula, or hemorrhage. Diverticular hemorrhage is associated with diverticulosis and not diverticulitis. Other presentations including those patients with fever, leukocytosis, and left-sided abdominal pain with an inammatory phlegmon are considered uncomplicated disease. This monograph examines the current evaluation and treatment of acute diverticulitis. The management of this common condition has changed considerably since the previous monograph on colonic diverticular disease.1

Historical Perspective
Diverticula were rst reported by Littre in the 1700s. These were felt to be pathologic curiosities and unlikely to cause symptoms.2 Fleischman rst used the term divertikel in 1815.3 In 1849, Cruvehiler described small herniations of the mucosa through the muscle layer of the sigmoid colon.4 A diagnosis of diverticulitis was considered so rare that it was not even mentioned in British surgical textbooks in the early part of the 20th century. With the increase in the use of contrast radiology after the rst
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World War, there was an increased acknowledgment of the prevalence of this disease. In 1907, Dr William Mayo reported 5 cases of diverticulitis to the American Surgical Association and demonstrated a modern understanding of the disease, stating that the surgical treatment depended on specic clinical factors and that, if signicant obstruction or infection was present, a temporary articial anus should be made.5 He advocated primary resection, stating that it was better to perform a primary resection of the affected part of the bowel, before abscess and stula supervened. Following Mayos modern day understanding of the disease, the trend in the USA and the UK reverted back to a 3-stage procedure as advocated by both Smithwick in 1942 and LockhartMummery in 1938.6,7 Staged resection with initial colostomy and drainage followed by resection of the involved segment and interval closure of the colostomy remained the standard treatment for diverticulitis for decades. The increased morbidity and disability for patients who had undergone staged procedures gave impetus to the initial resection of the affected segment, the current standard surgical treatment for patients with diverticulitis. More recently, reports of primary laparoscopic lavage without resection of the involved segment are challenging this dictum.8,9

Incidence
Diverticulosis is one of the most common colonic conditions in Western populations. Since the 20th century, an increasing prevalence of diverticular disease has been noted, particularly in industrialized nations. Diverticulosis is rare under the age of 30. Thereafter, the incidence of the diverticulosis is such that more than 40% develop diverticula by the age of 60 years and more than 60% of those aged 80 years or older are affected.10,11 The exact incidence of diverticulosis is difcult to determine but could presumably be determined by a combination of autopsy, radiographic, and endoscopic series. These data sources all have a number of limitations. The incidence in autopsy series varies with the interest of the individual pathologist in reporting the prevalence of diverticulosis. In the postmortem state, diverticula may only be detected by careful examination of the colon to detect small diverticula or diverticula obscured by mesenteric fat. The true prevalence of diverticulosis could theoretically be determined by performing barium enema studies on a large segment of the population. However, such studies are not ethically possible in an asymptomatic population because of the dose of radiation required. Colonoscopy and exible sigmoidoscopy series may also provide data on the prevalence of diverticulosis; however, many of the procedures are
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performed in symptomatic individuals, which would potentially overinate the numbers. In approximately 95% of cases, diverticula involve the sigmoid and left colon. With increasing age, the number of diverticula increase and they occur progressively more proximally. As a result, right-sided diverticular disease in Western societies is observed primarily in older patients in the setting of pan-diverticulosis with contiguous proximal spread.12,13 In contrast, diverticular disease in Asian countries occurs more commonly on the right side, with as many as 70% of the diverticula isolated to the right side.14-16 An estimated 10% to 25% of patients who develop diverticulosis will develop diverticulitis.17-21 This often quoted disease incidence is not population-based and is derived from old data sources. Given the presence of diverticulosis, the risk of developing diverticulitis does not seem to be related to the size, number, or extent of diverticula in the colon. Clinical data suggest that the incidence of diverticulitis is increasing. According to the Agency for Healthcare Research and Quality, more than 295,000 patient discharges for diverticulitis were reported at US hospitals in 2006.22 Etzioni and colleagues demonstrated that rates of admission and elective operations rose in the USA from 1998 to 2005. The rates of intervention rose dramatically for persons 18-44 years of age with the rates of admission increasing 82% and surgical intervention increasing to 73%.23 Ricciardi and colleagues examined the incidence of diverticulitis in the 1991 to 2005 period and noted a similar increase in diverticulitis discharges from 5.1 cases per 1000 inpatients in 1991 to 7.6 cases per 1000 inpatients in 2005 (P 0.0001). Although the proportion of diverticular abscess discharges as a fraction of all diverticulitis cases increased from 5.9% in 1991 to 9.6% in 2005 (P 0.0001), the proportion of free diverticular perforations remained unchanged (1.5%)24 (Fig 1).

Pathologic Features
Most colonic diverticula are considered pulsion or false diverticula. They contain only the mucosa and muscularis mucosa and not all layers of the bowel wall as a true diverticulum does. Diverticula appear macroscopically as saccular outpouchings of the colon and are generally small in size, ranging from 0.5 to 1.0 cm. They are acquired over time, in part, because of increased intraluminal pressures. Diverticula typically penetrate through the colonic wall in areas of relative weakness where the
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FIG 1. (A) Diverticulitis discharges (uncomplicated and complicated) in Nationwide Inpatient Sample from 1991 to 2005. (B) Proportion of patient discharges for free diverticular perforation among all patients with diverticulitis in Nationwide Inpatient Sample from 1991 to 2005. (Reprinted with permission from Ricciardi et al.24).

vasa recta penetrate the circular muscle layer, providing the blood supply for the mucous membrane. These herniations occur at well-dened points around the circumference of the colon along either side of the mesenteric tenia and on the mesenteric border of the 2 antimesenteric teniae25 (Fig 2). When there is no inammatory process, diverticula are soft and compressible, allowing a free communication between the diverticulum and the colonic lumen. Microscopic studies of areas of the colon with early small diverticula demonstrate areas of thinning due to presumed focal microscopic muscle atrophy.12 With progression, a clear-cut defect in the muscle occurs, usually at the site of penetration of a vessel through gaps in the circular muscle layer.
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FIG 2. Vasa recta penetrate the colonic wall at tenia libera, omentalis, and mesocolica. This allows herniation of mucosa and submucosa at these sites. (Color version of gure is available online.)

The exact pathogenesis of diverticulitis is uncertain. Similar to the development of acute appendicitis, it is postulated that stasis or obstruction of the diverticulum lead to bacterial overgrowth, localized tissue inammation, and ischemia. Once the colonic mucosa is injured, ulceration can occur, leading to a contained perforation and formation of a peridiverticular abscess or free perforation with peritonitis. The inammatory process can also stulize into adjacent organs such as the small bowel, bladder, and vagina. The most commonly isolated organisms are anaerobic bacteria, including Bacteroides, Peptostreptococcus, Clostridium, and Fusobacterium species and Gramnegative aerobes, especially Escherichia coli.26 Microscopic features of diverticulitis include thickening of the lamina propria secondary to inux of lymphocytes. Mucin depletion and Paneth cell hyperplasia can also be observed in addition to crypt abscesses and ulceration.27 Many of the histologic features are similar to those associated with inammatory bowel disease.28
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Pathophysiologic Features
The pathophysiology of the development of diverticulitis has focused on the structural abnormalities of the colon wall (termed a tenia specic elastosis), disordered motility and generation of high intracolonic pressures (segmentation), and the role of dietary ber.

Segmentation
Although the colon does represent a continuous column of gas and stool, high regional pressures can be generated within individual colonic segments. This process has been called segmentation and likened to the development of small compartments or segments within the sigmoid colon. This mechanism presumably leads to mucosal herniation and the development of diverticulosis.29,30 Painter and colleagues performed sigmoid manometry and cineradiography in patients with and without diverticular disease.29 The highest pressures were generated in the sigmoid colon. Patients with normal colons and patients with diverticular disease had similar resting luminal pressures29,31 but high-pressure waves occurred in patients with diverticular disease. In addition, patients with diverticular disease generated higher luminal pressures in response to a pharmaceutical stimulus such as the administration of morphine sulfate but not to meperidine. In subsequent studies, increased colonic motility (as evidenced by the number and amplitude of contractions) was noted in the sigmoid colon in patients with left-sided diverticular disease.32,33 The studies performed by Painter and others have a number of shortcomings. There were methodologic differences related to bowel preparation and the type of sensors used. A study period of 2 hours is relatively short and up to 24 hours may be needed to draw meaningful conclusions. The studies also involved a small number of patients and failed to account for age, gender, physical activities, or body fat percentage. Some have suggested that pressure-sensitive transducers that can be swallowed and allowed to pass through the gastrointestinal tract will give a more comprehensive measure of colonic physiology in diverticular disease.34 Other investigators have focused on myoelectrical activity in the colon to explain the development of diverticulosis. Myoelectrical studies have shown distinct slow wave motility patterns of patients with diverticular disease compared with irritable bowel syndrome.35 Patients with diverticular disease had abnormal slow wave motility patterns of 12 to 18 cycles/min, whereas patients with irritable bowel syndrome had a 3 cycle per minute motility pattern.35,36 Administration of bran had no effect on
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the motility of patients with irritable bowel syndrome, but in patients with diverticular disease administration of bran caused the motility patterns to return to normal.37 Of note, the abnormal motility patterns persisted in patients with diverticular disease despite sigmoid resection.38 Further physiologic studies demonstrate increased pressures and exaggerated motility indexes in patients with symptomatic diverticular disease.33,39 Patients with diverticular disease who are subjected to 24-hour manometric monitoring demonstrate abnormal propulsive activities that are specic to the affected regions of the colon.33 It is unclear, however, whether these motility and propulsion abnormalities are a byproduct of colonic disease or merely represent symptoms of diverticulitis.40

Role of Fiber
Diverticular disease has been called a ber-deciency disease of Western civilization. Early studies of diverticular disease compared populations in sub-Saharan Africa and the UK and concluded that the much higher incidence of diverticular disease in the UK was because of the amount of dietary ber consumed.41 Painter and Burkitt studied colonic transit times and stool weights in more than 1000 individuals in the UK and sub-Saharan Africa. Longer transit times and lower stool weights were seen in the UK population compared with the Ugandan population. A high ber diet was felt to be the major contributing factor to faster colonic transit times, larger stool volumes, and more frequent bowel movements. Painter and Burkitt reasoned that the rising incidence of diverticular disease in the Western world could be due to a gradual decrease in consumption of dietary ber over the course of the 20th century. Specically, the advent of roller milling and the process of rening sugar during the Industrial Revolution removed a large source of ber from the Western diet. The life expectancy of Western populations has increased over the 20th century and therefore one would anticipate an increase in the prevalence of diverticular disease with increasing age. Life expectancy remains low on the African continent and, therefore, as smaller numbers of the population reach older ages, a lower prevalence of diverticular disease should be expected.42 As Africans have adopted a more Western diet, authors have noted an increasing prevalence of diverticular disease has been noted.43 Animal studies have supported the role of dietary ber in the development of diverticular disease. In a prospective randomized trial of the effects of differing amounts of ber in 1800 rats, Fisher and colleagues demonstrated a dramatic increase in the number of rats with diverticulosis when fed low ber diets compared with those fed high ber diets.44
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Approximately 45% of the rats on the lowest ber diet developed diverticula compared with 9% of the rats on the highest ber diet. Two studies have examined dietary factors in large populations of patients with and without diverticular disease.45,46 Both studies have demonstrated signicantly lower consumption of dietary ber in patients with diverticular disease when compared with their healthy counterparts. Patients with diverticulosis also tended to eat greater quantities of red meat and fats. Aldoori and colleagues studied 51,529 male health professionals and over a 6-year period there were 384 (0.75%) new cases of diverticular disease. The risk of the development of diverticular disease was inversely associated with insoluble dietary ber intake. The relative risks associated with fruit and vegetable ber were 0.62 (95% CI 0.45-0.86) and 0.55 (95% CI 0.37-0.84).45 Fiber found in fruits and vegetables conferred the most protective effect (compared with ber from cereal) and a high intake of total fat and red meat increased the incidence of diverticular disease. Manousus and colleagues46 compared a cohort of individuals who were predominantly vegetarians to a cohort who predominantly ate meat and consumed very few vegetables. Diverticulosis was dened as the presence of 3 of more diverticula on barium enema study. In this study, 100 patients with radiographically conrmed diverticulosis and 110 control patients were compared using a structured interview that included questions pertaining to dietary intake, demographic, and socioeconomic factors; they concluded that higher reported consumption of meat and dairy products was associated with development of diverticulitis. The risk of developing diverticular disease was 50-fold greater in meat eaters. Although these studies have potential confounding variables including detection and recall bias, they support the role of dietary ber. Furthermore, in a large cohort study of 47,228 men, popcorn, nut, and seed consumption was inversely correlated with diverticulosis or diverticular complications.47 This study refutes the adage that nuts, corn, seeds, and popcorn cause diverticulitis and should be avoided in patients who have had an attack of diverticulitis.47

Colonic Wall Abnormalities and Tenia Specic Elastosis


Alternative theories to the traditional low ber hypothesis have been proposed. Some investigators have suggested that the smooth muscle of the rectosigmoid behaves differently from other muscles in the colon wall. This was theorized because often wall thickening was the only abnormality in the absence of inammation.48 Early necropsy studies describe increased bowel wall thickness in patients with diverticular disease.25 Although this was initially felt to be from muscular hypertroCurr Probl Surg, September 2010 687

phy, multiple subsequent studies have shown that there is no evidence of either hypertrophy or hyperplasia. Whiteway and Morson proposed that this thickening was due to elastin deposition within the tenia.49 Whiteway and Morson studied the muscularis propria in patients with uncomplicated diverticulosis and found that the tenia were thickened due to elastin deposition. There was an increase of over 200% in elastin in these patients compared with controls. The elastin was laid down in a contracted form, leading to bunching of the tenia and apparent foreshortening of the bowel. Furthermore, with progressive scarring in diverticulitis, the ratio of type I to type III collagen is altered in both the serosa and the submucosa.50 Some have postulated that this effect is secondary to aberrant activity of matrix metalloproeinases and tissue inhibitors of the matrix metalloproteinases.51 It remains to be seen whether the role of matrix metalloproeinases and tissue inhibitors of the matrix metalloproteinases is specic to acute inammation or to diverticular disease.52 Despite the grossly increased muscle wall thickness, patients with diverticulosis remain more susceptible to herniation. The role of collagen and the tensile strength of the colonic wall have been investigated. Wess and colleagues analyzed colonic collagen content in an attempt to determine if a lack of collagen is responsible for this apparent weakness of the muscle wall.53 Since the collagen content does not change with age or the presence of diverticula, the changes are more likely to be qualitative than quantitative. Collagen brils demonstrate increased cross-linking with increased age; this process seems to increase most dramatically after 40 years of age, the age at which the incidence of diverticular disease also appears to increase. This same study demonstrated that patients with diverticulosis have an abnormally high amount of collagen cross-linkage in the colon wall. This difference persists even when patients were compared with age-matched controls. Increased cross-linkage of collagen bers likely causes the tissues to become stiffer and less resistant to stretching. The loss of compliance of the colonic submucosa, the layer primarily responsible for tensile strength, may make the submucosa more susceptible to small tears when subjected to the higher intraluminal pressures triggered by segmentation. Any tear in this layer could potentially then lead to mucosal herniations and the formation of diverticulosis. A possible genetic connective tissue defect has also been suggested because of reports of diverticular disease in young patients with Marfan syndrome or EhlersDanlos syndrome.54-56 It is likely that a number of processes including impaired motility, low ber intake, inammation, and elastin deposition contribute to the pathogenesis of diverticular disease.
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Additional Risk Factors


Age. From a historical standpoint, diverticulitis in younger patients (under the age of 50 years) has been described as more virulent and more likely to be associated with complications and more likely to require resection.57,58 Young patients have been variably dened as under 50 years in some series and under 40 or 45 years old in other series. Despite the denition of what age denes young patients, all series of younger patients with acute diverticulitis have noted a striking male predominance in contrast to older series, which have a slight female predominance.59 Earlier series of young patients in the pre-computed tomography (CT) scan era have had a large percentage of patients undergoing resection, presumably since the patients were frequently diagnosed preoperatively with appendicitis. These patients then underwent laparotomy and subsequent resection when diverticulitis and not appendicitis was encountered. Currently, such patients would most likely be diagnosed with acute diverticulitis on CT scan preoperatively and treated with initial medical management of bowel rest and antibiotics. The current management of young patients with diverticulitis continues to be a source of considerable controversy and is discussed later in this text. Sex. Diverticular disease tends to affect patients during middle age as the incidence rises from 5% at age 40 to 80% by age 80.60 The prevalence of the disease among the sexes has been estimated to be between a 2:3 and 3:1 male-to-female ratio.21,61 Other authors have reported that patients with symptomatic diverticular disease younger than the age of 65 tend to be male. Hall and colleagues demonstrated that younger male patients may present with more severe CT ndings of diverticulitis than female patients.62 Recent data suggest that men have a higher incidence of diverticular bleeding, whereas obstructions are more common among women.63 Geographic Factors. Geographic location also appears to play an important role in the incidence of diverticulitis. Diverticulitis appears to be much less common in Asian populations.41 When diverticulitis does occur, it tends to involve the right-sided colon in contrast to the sigmoid colon as is common in Western populations.56 There is a clear relationship between increasing industrialization and incidence of this disease. Several studies have documented the low prevalence of the disease in African nations.64-66 Other authors have noted increased rates of diverticulitis in Africans with increased penetration of Western lifestyle patterns.67 Reports from both Japan and Singapore have reported inCurr Probl Surg, September 2010 689

creases in prevalence approaching 20%. This is thought to be due to the increased acceptance of Western diets.68,69 Physical Activity. Two studies have examined the effect of exercise on the development of diverticular disease.70,71 The risk of developing diverticular disease and levels of physical activity appear to be inversely related. This difference persisted even when the authors adjusted differences in dietary ber intake. A potential drawback of the study is that the differences may have arisen from the fact that ability to exercise might have been impaired or prohibited by symptoms of diverticular disease.70 Smoking. The potential association between diverticular disease and smoking is contradictory. One large case-control study demonstrated that smokers had 3 times the risk of developing complications from diverticular disease than did nonsmokers.72 Another large cohort study of 46,000 men in the USA failed to show a similar association.71 Nonsteroidal Anti-Inammatory Agents. The use of nonsteroidal anti-inammatory agents (NSAIDs) has been associated with the development of multiple gastrointestinal complications. Evidence suggests that chronic NSAID use is almost twice as common in patients with diverticular disease as healthy controls with no known colonic disease.73,74 While the health professionals follow-up study showed an increased incidence of uncomplicated diverticular disease in patients who used NSAIDs compared with their asymptomatic counterparts, additional studies have noted an increased risk of complicated diverticulitis with NSAID use.75 A retrospective study by Corder demonstrated a 23% higher risk of perforating diverticulitis in patients who took NSAIDs regularly compared with patients with diverticular disease who did not take NSAIDs.76 An additional study of hospitalized patients demonstrated chronic NSAID use to be much higher in patients admitted with diverticular disease than the population as a whole. In addition these patients were 4 times more likely to develop perforated diverticulitis than patients with no history of NSAID use.77 Caffeine Ingestion. Caffeine intake has been investigated as a possible contributing factor to the development of diverticular disease as caffeine stimulates small bowel secretion and may also affect colonic transit time.78 When caffeine consumption was evaluated in groups of patients with and without diverticular disease, no difference was identied.71 Obesity. Several retrospective case series have noted a striking preponderance of obese patients with diverticulitis, particularly patients under the age of 40.58,79,80 In addition, 2 prospective cohort studies (the Health Professionals Follow-up Study and a Swedish study) have shown an association between body mass index (BMI) and diverticular dis690 Curr Probl Surg, September 2010

ease.71,81,82 The USA Health Professionals study has shown an increased risk of diverticulitis and diverticular bleeding not only with increasing BMI, but also waist circumference and waist-to-hip ratio.81 Obesity has been linked not only to inammation but also to differences in the intestinal ora, which may be potential mechanisms for the increased risk of diverticulitis.83-85

Development of Symptoms
Although most patients with diverticulosis remain asymptomatic, approximately 10% to 25% of patients develop symptoms ranging from mild abdominal pain to peritonitis and signs of sepsis. The pathophysiologic factors underlying the differential presentations of this disease are unknown. Several authors have proposed that the development of symptoms involves several inter-related processes including muscular dysfunction, inammation, and visceral hypersensitivity.86-88 The degree of inammation present with diverticulitis is variable and has been difcult to correlate with symptoms. Horgan and colleagues retrospectively reviewed 47 patients who underwent resection for diverticular disease.89 They reported a syndrome of smoldering diverticulitis that occurred in patients with chronic left lower quadrant pain but did not have associated fever or leukocytosis. Seven patients had previously undetected pericolic abscesses and 76% had evidence of acute and chronic mucosal inammation. More than three quarters of patients had resolution of symptoms after resection. There was no correlation between the extent of resection, the duration of symptoms, and the preoperative endoscopic evidence of inammation. Similarly, Morson found no evidence of colonic inammation in one third of patients who had resection for diverticular disease.48 Although some patients may have resolved the inammatory change before elective resection, this nding suggests a weak correlation at best between the degree of inammation and symptoms in diverticular disease. Inammation. Inammatory change associated with diverticulitis is most often termed acute diverticulitis, describing systemic symptoms associated with peritoneal inammation including left lower quadrant pain, fever, and leukocytosis. Luminal mucosal inammation may also be associated with colonic diverticula and have some features of inammatory bowel disease.90 This entity has also been called segmental colitis, sigmoiditis, and diverticular colitis.91-93 The clinical signicance of this entity is not known and the incidence is low; the nding has been noted in 0.25% to 1.5% of colonoscopies performed.90,94 However, due to lack of an established denition and variation in reporting, the exact clinical
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course of diverticular colitis is difcult to determine. It has been suggested that diverticular-associated colitis is a distinct entity, although the clinical manifestations overlap inammatory bowel disease.95

Visceral Hypersensitivity and Post Inammatory Neuronal Damage


Persistent colonic symptoms, especially abdominal pain, have been reported after resolution of infectious enteritis and inammatory bowel disease and may also occur after resolution of an episode of acute diverticulitis. It has been suggested that the sharp pain represents visceral hypersensitivity of excessive perception or an excessive afferent response to stimuli.87 The pain appears to be related temporally to contractions in the sigmoid colon and has been noted in patients with symptomatic disease. This type of pain has not been observed in patients with otherwise asymptomatic diverticulosis.33,96,97 Thus, persistent symptoms after resolution of an episode of diverticulitis may represent visceral hypersensitivity and not ongoing inammation. Patients with acute diverticulitis have also been noted to have increased nerve staining in the muscularis propria compared with control patients, in addition to increased staining in the mucosa and submucosa.86 The neurons are of smaller diameter, suggesting proliferation in response to inammation. Nerve damage in patients who have had diverticulitis has been documented and it is postulated that this may represent regeneration and hyperinnervation and contribute to ongoing symptoms.86,98,99 Patients with diverticular disease have been shown to have increased neuropeptides in mucosal biopsies, which may also represent prior inammation.100

Clinical Manifestations of Diverticular Disease


There are 3 main clinical presentations of diverticular disease (Table 1). The most common clinical presentation of diverticulitis is left-sided abdominal pain with or without an associated mass, fever, and leukocytosis. Patients generally resolve the acute episode after treatment with antibiotics. Another manifestation is smoldering disease that only partially improves with antibiotics and medical therapy. Such patients have recurrent symptoms that can manifest with ongoing low grade fever and left-sided abdominal pain. CT scans on such patients generally will demonstrate a persistent phlegmon and these patients require resection for ongoing symptoms. Many patients present with associated obstruction, abscess, stula, or perforation. The approach to these patients is discussed
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TABLE 1. Typical presentation patterns of diverticulitis Acute diverticulitis Typical, relapsing (chronic) Subacute Complicated diverticulitis Obstruction Mass/abscess Fistula Hemorrhage Perforation Chronic diverticulitis Atypical Atypical site (transverse, ascending)

in the section on complicated diverticular disease. Finally, a small group of patients may have atypical presentations for diverticulitis. These patients may have chronic left lower quadrant pain and diverticulosis but lack objective evidence of diverticulitis such as fever leukocytosis or objective ndings on CT scan. There is considerable overlap with irritable bowel syndrome in this group of patients, who are challenging both to diagnose and to manage.

Clinical Symptoms and Physical Exam


The clinical presentation of diverticular disease is dependent on the extent of the disease process. Patients with acute diverticulitis typically present with left-sided abdominal pain, fever, and leukocytosis. With a signicant phlegmon or abscess, an abdominal mass may be appreciated on rectal or pelvic examination. The tenderness is often associated with some degree of abdominal distention or signs of ileus. Patients with a redundant sigmoid colon may have predominant right-sided tenderness. Free perforation is associated with diffuse abdominal pain and sometimes referred pain in the shoulder. Patients often describe changes in their bowel habits such as diarrhea or an alteration in stool caliber. Rectal bleeding is uncommon and, if present, is more consistent with ischemic colitis or inammatory bowel disease than diverticulitis. Nausea and vomiting may be seen with associated small or large bowel obstruction. Patients with stulas may have minimal abdominal complaints and may present initially to a urologist or gynecologist. Patients who develop complications of diverticular disease such as colovesical stulas may present with pneumaturia, pyuria, or fecaluria, whereas patients with colovaginal stulas may present with vaginal discharge, vaginal air, or stool per vagina.
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A number of patients with chronic diverticular disease will present with pain as their predominant symptom in the absence of other physical ndings. The pain is typically persistent and boring, remaining constant over long periods. It does not tend to be crampy in nature as in patients with irritable bowel syndrome, but is difcult to distinguish from this entity. These patients have diverticulosis on contrast examination or CT scans but seldom have features of obstruction, perforation, stricture, or abscess formation. Most authors have suggested that these patients should have symptoms for 6 months before meriting a resection.89

Differential Diagnosis
The differential diagnosis for patients with suspected diverticular disease includes appendicitis, bowel obstruction, colorectal cancer, gynecologic disease, inammatory bowel disease (especially Crohns disease), irritable bowel syndrome, ischemic colitis, and pyelonephritis. Other diagnoses that should be entertained depending on the clinical scenario include tubo-ovarian abscess, pelvic inammatory disease, ureteral calculi, volvulus, stercoral ulcer, ovarian torsion, and endometriosis. Modern cross-sectional imaging is often helpful in diagnosing many of these clinical entities. The most important diagnosis to exclude on initial presentation is colorectal cancer. CT scanning conrms a diagnosis of diverticular disease but is also helpful in excluding other intra-abdominal clinical entities.

Uncomplicated Disease
Laboratory and Diagnostic Imaging
Most patients with acute diverticulitis have an elevated white blood cell count. Patients with a colovesical stula may have an abnormal urinalysis and/or culture. Polymicrobial urine cultures are common. Although several different modalities have been used to evaluate patients with suspected diverticular disease, CT has emerged as the study of choice. Flat and upright plain lms of the abdomen are commonly obtained in the evaluation of the patient with acute abdominal pain to exclude obstruction or free intraperitoneal air. In patients with diverticular disease the ndings of plain lms tend to be nonspecic.101 Contrast enemas are seldom currently used in the evaluation and management of diverticulitis. Findings suggestive of diverticulitis on contrast enema studies include diverticula, fold thickening, spasm, intramural sinus tract, tethering of the colon wall, and extravasation of contrast. Well-performed barium studies are able to distinguish ne
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mucosal detail and can demonstrate muscular rigidity as well as tubularization of the lumen. Water-soluble contrast studies can be of particular utility in acute settings in which there is a potential need for urgent surgery or a possible perforation is suspected. Barium administration under these circumstances is relatively contraindicated.102 In patients who present with obstipation, water-soluble contrast can assist in relieving a partial obstruction. In specialized settings, ultrasound has been demonstrated to be an effective test in the diagnosis of acute diverticulitis. Mural thickening, extraluminal air, pericolic abscess, and hyperechogenic fat were ndings that were suggestive of the diagnosis.103 Ultrasound has not gained wide acceptance in the USA. The most widely available and accurate examination of patients with acute abdominal pain is the abdominal CT. Advantages of CT scanning include the ability to make an accurate diagnosis and stage the severity of disease, and the therapeutic ability to drain an abscess with CT guidance. Disadvantages of CT scan include radiation exposure and the cost of the examinations. For evaluation of acute diverticulitis, CT has an additional benet since it assesses the extraluminal ndings, the predominant ndings in acute diverticulitis. CT ndings consistent with diverticulitis were rst described more than 25 years ago. These signs included the presence of diverticula, pericolic fat stranding, colonic wall thickening more than 4 mm, and abscess formation.104 CT has the added advantage of detecting other intraperitoneal ndings, including hepatic abscesses, pyelophlebitis, small bowel obstruction, colonic strictures/obstruction, and colovesical stulas. Ambrosetti and colleagues rst proposed a system for classifying the severity of diverticulitis on CT ndings to guide clinical management. CT ndings consistent with mild diverticulitis included localized wall thickening (5 mm) and inammation of the pericolic fat. Severe CT ndings were the combination of localized wall thickening and inammation of the pericolic fat with abscess, extraluminal air, or extraluminal contrast (Table 2). Patients with severe CT ndings underwent operative intervention more frequently than those patients with mild ndings (33% vs 15%). Patients younger than 50 years of age with severe ndings on CT scan were also more likely to have recurrences or complications.105 These early ndings have been evaluated prospectively and conrmed in a cohort of 502 patients. Compared with patients with mild diverticulitis, patients with ndings of severe diverticulitis on CT scan were more likely to have recurrent attacks of diverticulitis after an initial attack of
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TABLE 2. Ambrosetti CT criteria for diverticulitis severity137 Mild diverticulitis Severe diverticulitis Wall thickening (5 mm) Pericolic fat stranding Wall thickening (5 mm) Pericolic fat stranding with Abscess Extraluminal air Extraluminal contrast

TABLE 3. Modied Hinchey classication system146 Stage Stage Stage Stage Stage Stage 0 Ia Ib II III IV Mild clinical diverticulitis Conned pericolic inammation---phlegmon Conned pericolic abscess (within sigmoid mesocolon) Pelvic, distant intra-abdominal or intraperitoneal abscess Generalized purulent peritonitis Fecal peritonitis

acute diverticulitis treated with antibiotics (39% vs 14%). In this cohort of patients, CT was preferable to contrast enema in the diagnosis and management of acute diverticulitis.106 Poletti and colleagues explored CT and demographic predictors for nonoperative treatment failure in 312 patients with a rst episode of left-sided diverticulitis and concluded that the presence of an abscess or extraluminal air more than 5 mm in diameter were signicant predictors of treatment failure.107 CT ndings that are relevant to clinical management were reclassied into a classication system based on the Hinchey classication system (Table 3). In Grade 0 there is colonic wall thickening but not pericolonic fat stranding. Grade 1a consists of wall thickening and pericolonic fat stranding, while Grade 1b includes a pericolonic or mesocolic abscess. Patients with Grade 2 disease have distant intra-abdominal or pelvic abscesses. Patients with Grade 3 and Grade 4 disease have purulent and fecal peritonitis, respectively. CT is somewhat limited in distinguishing between patients with Grade 3 and Grade 4 disease since purulent and fecal peritonitis often cannot be distinguished on imaging108 (Figs 3-5). Although the study power was limited, Kaiser and colleagues found that disease severity using the modied CT Hinchey classication system correlated with postoperative morbidity and mortality. They also found that the CT stage correlated with recurrence when patients were managed nonoperatively. The presence of a diverticulitis-associated abscess was 1 particular factor that was highly associated with high risk of failure of nonoperative management. These authors suggested that patients who
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FIG 3. Modied Hinchey stage Ia diverticulitis. Arrow points to pericolic inammation and phlegmon.

were admitted with a diverticular abscess should receive strong consideration of an elective resection.109 Endoscopic procedures (exible sigmoidoscopy and colonoscopy) are generally not advocated during an acute episode of diverticulitis. A delay of 6 weeks following resolution of symptoms is recommended. This approach is encouraged to avoid potential conversion of a sealed microperforation into a free perforation.110 This approach has been questioned by other groups who have demonstrated that colonoscopy during an acute episode of diverticutlitis can be safe. Even when optical examination of the colon is performed in the acute setting, a substantial number of the procedures cannot be completed.110,111 Cytoscopy or cystography has been used to identify suspected colovesical stulas. In the CT scan era, however, the presence of air in the urinary bladder in the absence of instrumentation is considered diagnostic.112

Treatment of Uncomplicated Diverticulitis


Medical Treatment Antibiotics. The mainstay of therapy for management of uncomplicated diverticulitis is antibiotic therapy. Despite the broad application of antibiotics in the operative and nonoperative therapy of diverticulitis,
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FIG 4. Modied Hinchey stage II diverticulitis. Arrow points to pelvic abscess.

there have been few studies examining the optimal administration of these agents.113 Diverticula are thin-walled structures that are thought to perforate and spill intracolonic contents and bacteria into the surrounding tissue. Thus, the microora associated with diverticular disease include the normal colonic ora such as gram-negative rods, gram-positive rods, and anaerobic bacteria. The anaerobic bacteria are far more common and outnumber the aerobic 1000:1.114 When the microbiological proles of patients with perforated diverticultis were reviewed, 75% of specimens were polymicrobial: 71% of patients cultured E. coli, 10% of patients had Group D Streptococcus (Enterococcus), and 50% of the specimens isolated Bacteroides fragilis.26 Patients with minimal systemic symptoms and mild signs of peritoneal irritation can typically be treated as outpatients. Patients receive broad spectrum antibiotics for 7 to 14 days. Despite their common use, there are few data regarding the optimal length of treatment with antibiotics.
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FIG 5. (A) Modied Hinchey stage III diverticulitis. Arrow points to free uid. (B) Modied Hinchey stage III diverticulitis. Arrow points to free air. (C) Modied Hinchey stage III diverticulitis. Demonstrates intra-abdominal free uid. (D) Modied Hinchey stage III diverticulitis. Arrow points to pelvic uid.

Patients who present with fever, systemic symptoms, or inability to tolerate oral intake are usually hospitalized. Parenteral antibiotics are typically administered until the acute symptoms resolve. Once there is clinical improvement, the antibiotic route is changed to oral administration. There are several single and combination antibiotic regimens for the management of acute diverticulitis. All the regimens have activity against the colonic ora; however, little is known about their efcacy.114 Kellum and colleagues randomized 51 patients to a regimen of cefoxitin alone versus gentamicin/clindamycin. Patients in need of an urgent operation were excluded. These authors concluded that the single-agent regimen exhibited similar efcacy to the 2-agent regimen. They recommended the use of cefoxitin since this was cost-effective.115 The American College of Gastroenterology guidelines for the treatment of diverticulitis include cefoxitin or ampicillin/sulbactam as single agents, or a third-generation cephalosporin, aminoglycoside, or monobactam in
Curr Probl Surg, September 2010 699

combination with an antianaerobic agent.116 The American Society of Colon and Rectal Surgeons published their practice parameters for the management of diverticulitis in 2006. They recommended that antibiotic therapy be selected to provide adequate coverage of the most common colonic organisms. The authors maintained that single and combination regimens were equally effective. Even with appropriate antibiotic therapy, approximately one third of patients will have a recurrence.17 Diet. A high ber diet increases the bulkiness of stools, decreases colonic transit time, and therefore decreases intraluminal pressures.40 The optimal amount of daily ber is unknown; however, 20 to 30 g is a widely recommended gure. Recent evidence supports the notion that individuals with diets high in ber have decreased rates of diverticulosis and bear a lower risk of developing diverticulitis.45-47 Emerging Medical Therapies Mesalamine. There has been increased interest in the use of immunomodulatory agents in the management of diverticular disease. 5-ASA compounds and sulfazalazine are widely used in the management of inammatory bowel disease. 5-ASA products alter DNA synthesis and cell cycle progression in lymphocytes. 5-ASA compounds are also thought to suppress leukotriene and prostaglandin synthesis, as well as decrease leukocyte adhesion, thus reducing proinammatory states.117,118 Because a low-grade proinammatory state is the proposed mechanism underlying chronic diveriticular disease, a number of small trials have evaluated the effectiveness of mesalamine-like compounds. In virtually all of these studies the outcome of interest was symptom severity and change in bowel habits. In the original description of the use of mesalamine for the management of diverticulitis, Trespi and colleagues demonstrated that patients treated with rifaximin, ampicillin/sulbactam, and mesalamine had decreased symtomatology and were less likely to experience microhemorrhagic phenomenon.119 Another study randomized patients with at least 2 episodes of acute diverticulitis to a rifaximin-only arm versus a rifaximin/mesalamine arm. Patients in the rifaximin/mesalamine arm demonstrated signicantly improved bowel habits, episodes of recurrence, and symptom severity.120 In another study, mesalamine alone was compared with rifaximin alone. Although there were only 170 patients in the study, the authors compared 11 outcome variables including nausea, emesis, dysuria, general illness, fever, abdominal tenderness, diarrhea, tenesmus, bloating, and abdominal pain/discomfort. Patients treated with mesalamine had statistically significant lower global score than patients treated with rifaximin alone. These authors concluded that mesalamine is an effective medication for pre700 Curr Probl Surg, September 2010

venting recurrence of diverticulitis and maintaining remission.121 Other authors have demonstrated that daily treatment with mesalamine is more effective than cyclic treament.122 In a systematic review of 818 patients in 6 randomized trials of 5-ASA products in the treatment of diverticulitis, patients treated with 5-ASA products had better outcomes than those not treated with 5-ASA. They also concluded, however, that larger trials which had objective conrmation of the diagnosis by endoscopy are needed for conrmation of the initial data on this type of treatment.123 Probiotics. Probiotics are dened as preparations of naturally occurring colonic microora that can exert a benecial health effect on the host organism. Patients with diverticular disease are thought to have altered colonic microora due to constipation and stasis of fecal matter.124 Administration of these preparations is thought to restore healthy colonic microora. Giaccari and colleagues examined the administration of rifaximin followed by Lactobacillus for 12 months in 79 patients with diverticular disease. They reported no new complications and adequate symptom control. They concluded that the combination of rifaximin and lactobacillus was an adequate regimen for prophylaxis against the complications of diverticular disease.125 In a smaller study (15 patients), investigators compared administration of nonpathogenic E. coli with active coal tablets to coal tablets alone. These authors concluded that the length of remission was signicantly longer when a probiotic was administered (14 vs 2.4 months).126 Although the initial results are promising, there are only a small amount of data supporting the use of probiotics and larger, preferably randomized, trials are needed to conrm the initial results. Follow-Up After Successful Medical Treatment. Examination of the colon following a presumed attack of diverticulitis should be carried out to exclude the presence of malignancy or Crohns disease. Some authors have demonstrated that CT ndings on the patients initial CT scan can be used to assist in differentiating diverticulitis from a malignancy. Fluid at the base of the mesentery and vascular engorgement were found to be highly specic for the diagnosis of diverticulitis.127 Chintapalli and colleagues retrospectively examined the CT scans of patients with known cancer or diverticulitis. This group determined that enlarged lymph nodes were observed more frequently in the patients with colorectal cancer (71% vs 15%).128 In more recent data, other groups have compared the perfusion characteristics of patients with colorectal cancer to those with diverticular disease. Patients with colorectal cancer tended to have higher blood volume, transit time, and permeability in comparison with patients
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with diverticulitis. This study also conrmed that patients with colorectal cancer have more pericolonic nodes.129 Optical colonoscopy or exible sigmoidoscopy combined with contrast enema are the preferred methods of examining the colon following an attack of diverticulitis. The American Society of Colon and Rectal Surgeons published practice parameters for the management of sigmoid diverticulitis in 2006.17 The society did not specically recommend any specic time delay for these studies following an attack. Other authors recommend a delay of 6 weeks following resolution of symptoms. This approach is encouraged to avoid potential conversion of a sealed microperforation into a free perforation.110 Indications for Elective Surgical Management. Until recently, the indications for surgical management of diverticulitis were straightforward. The goals of surgery for diverticulitis are to resect the sigmoid colon, restore intestinal continuity, and minimize the chance of anastomotic complications and recurrent diverticulitis. Elective resection was advocated after 2 well-documented attacks of uncomplicated diverticulitis requiring hospitalization, and/or after 1 episode of complicated diverticulitis. In patients younger than 40 years of age, elective resection was recommended after the rst attack of complicated or uncomplicated diverticulitis since the disease was generally considered more aggressive in young patients. These guidelines were endorsed by a number of societies including the American Society of Colon and Rectal Surgeons, the Society for Surgery of the Alimentary Tract, the European Association for Endoscopic Surgery, and the American College of Gastroenterology.116,130-132 Recently, several of these recommendations have been challenged. Salem and Flum suggested that waiting until the fourth attack of uncomplicated diverticular disease would be associated with fewer deaths and fewer intestinal stomas.133 Another decision analysis concluded that elective resection after the third attack would be more cost-effective.134 Furthermore, a number of large reviews have suggested that the common practice of operating after the second episode of diverticulitis should be reconsidered.20,135 The guidelines for surgery have been revised and the American Society of Colon and Rectal Surgeons currently states that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in dening the appropriateness of surgery.17 Recommendations should be inuenced by the age and medical condition of the patient, the severity and frequency of the attacks, and the presence of ongoing symptoms. Furthermore, most patients who present with complicated diverticulitis will have complicated disease on the rst attack; resection after recovery
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from uncomplicated diverticulitis does not prevent the development of complicated diverticulitis.135,136 Thus, the indications for elective sigmoid resection are determined by the severity of disease, the risk of subsequent attacks of diverticulitis, and complications of the disease in addition to the age and other comorbidities of the patient. Young Patients. Previous recommendations have advocated sigmoid resection for young patients after 1 well-established attack of diverticulitis;132 however, this dictum has been called into question by recent evidence. The management of young patients with diverticulitis remains controversial. Several authors have proposed that patients younger than 40 to 50 years of age present with a more virulent form of diverticulitis.137 Although younger men are proposed to have severe diverticulitis more often than older men, they required operative intervention less frequently.105 Other authors have challenged this view, pointing out that younger patients did not have different rates of conservative management, emergency operation, or mortality.133 In a recent series, patients younger that 50 years of age were found to present more frequently with evidence of severe disease on abdominal CT. It is unclear how this fact translates into their ultimate clinical outcome.62 Although there is some evidence that young patients present with a more virulent form of the disease, it is not clear that these patients will go on to have a recurrence. In a study by Guzzo and Hyman, 1 patient out of 196 young patients (50 years) had a free perforation after medical management of diverticulitis. The median follow-up was 60 months. Given the current level of evidence, there is no clear mandate to treat young patients with diverticulitis differently from other age groups.138 Several series have noted an increasing percentage of young patients with diverticulitis. Young patients with diverticulitis have comprised 18% to 34% of recent series62,138-141 compared with 1.3% to 8.2% of patients in older series.142,143 With the ability of CT scanning to stratify patients with mild or more severe diverticulitis, several studies have noted that young patients have more severe disease compared with other cohorts. Chautems and colleagues compared patients younger than 50 and over the age of 50 with mild and severe disease. Mild disease was dened as mild inammatory change on CT scanning and severe disease was dened as association with microperforation, etc. There were 28 patients younger than 50 and 50% had mild disease and 50% had severe disease. Over the age of 50, 74 patients had mild disease and 16 patients had severe disease. The risk of a poor outcome (generally dened as the need for operative intervention) was 54% in young patients with severe disease and 44% in patients over
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TABLE 4. Hinchey classication system145 Stage Stage Stage Stage I II III IV Pericolic or mesenteric abscess Pelvic or retroperitoneal abscess Purulent peritonitis Feculent peritonitis

the age of 50 with severe disease. Thus, although the risk of poor outcome with severe disease in young patients was relatively equivalent to older patients with severe disease, a higher percentage of young patients had evidence of severe disease.136 In a review of 932 patients, Hall and colleagues noted similar ndings. Young patients were more likely to present with evidence of severe disease on CT scan than older patients (19.3% vs 11.5%).62 The dictum that diverticulitis in young patients has a more virulent course has been challenged. Vignati and colleagues noted that younger patients with diverticulitis had an identical clinical course compared with older patients.144 In another review of 196 young patients followed for a median of 60 months, only 1 patient presented with free perforation after initial medical management of acute diverticulitis. Salem and Flum have noted that younger patients had no different rates of conservative management, need for emergency operation, or mortality.133

Complicated Diverticular Disease


Complicated diverticulitis generally refers to diverticulitis associated with perforation, stula, abscess, stricture, or obstruction. Diverticular bleeding is associated with diverticulosis and not diverticulitis. In an effort to be able to compare different groups of patients with perforation/abscess, the Hinchey classication has been used and is divided into stages I to IV.145 Stage I is diverticulitis associated with pericolic abscess; stage II is a more distant abscess such as a pelvic or retroperitoneal abscess. Stage III is purulent peritonitis, and stage IV is fecal peritonitis. Modications of the Hinchey classication have been made by Warsavary and colleagues146 (Table 3) and used by others,109 but the original Hinchey classication remains the most common classication system used (Table 4). Other scoring systems such as the Mannheim Peritonitis Index and the colorectal (Cr)POSSUM (the colorectal physiological and operative severity score for the enumeration of mortality and morbidity) may be better tools to assess operative risk in the future.147,148 Management of complicated diverticular disease is dependent on the particular presentation of the disease. Treatment of the complications of
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FIG 6. Proportion of patient discharges for diverticular abscess among all patients with diverticulitis in Nationwide Inpatient Sample from 1991 to 2005. (Reprinted with permission from Ricciardi et al.24)

diverticulitis may range from treatment with bowel rest and parenteral antibiotics to emergent exploratory laparotomy. We review the treatment options for each of the complications of diverticulitis separately.

Diverticular Abscess
Diverticular abscess occurs in approximately 15% of patients with acute diverticulitis. Abscesses include pericolic, pelvic, and retroperitoneal abscesses. In women, involvement of the left ovary may result in tubo-ovarian abscesses.149 Data from the Nationwide Inpatient Sample, the largest source of all-payer hospital discharge information in the USA, suggests an increase in the number of patients with diverticular abscess in the last decade24 (Fig 6). This may be due to the widespread use of CT scanning since previously patients were often treated empirically with antibiotics and small abscesses may not have been detected. Furthermore, CT scanning on initial presentation may also lead to increased detection of small uid collections associated with diverticulitis, which may not necessarily be abscesses. In patients with diverticulitis and an associated abscess, the goal has previously been to treat the inammatory process and ideally to operate on an elective basis when the risk of infectious complications is substantially lower, therefore optimizing the ability to safely perform a resection and anastomosis. The management of diverticular abscess changed in 1986 with the report of Saini and colleagues, who reported percutaneous drainage of diverticular abscess followed by a single-stage
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resection in 7 of 8 patients.150 The surgical dictum has been to ultimately perform resection on all patients after percutaneous drainage since more than 40% will develop recurrent sepsis.109 However, reports of patients who have undergone percutaneous or operative drainage with no further septic sequelae have called this practice into question. Franklin and colleagues reported on 18 patients who underwent laparoscopic drainage of Hinchey II abscess and, at a follow-up of 4 to 34 months, 15 remained asymptomatic without the need to undergo resection.151 The debate about the management of diverticular abscesses centers on determining which patients can be treated with antibiotics alone, which patients require percutaneous drainage, and which patients require urgent or emergent surgery. CT scanning has been the mainstay of diagnosis of intra-abdominal abscess and also allows for exclusion of other causes of acute abdominal pain. For patients with mild diverticulitis or conned pericolic inammation (phlegmon), there is general consensus that bowel rest and antibiotics are generally effective. Similarly, there is general consensus that patients with perforated diverticulitis manifested by purulent peritonitis or feculent peritonitis require operative intervention. The management strategy for patients with pericolic or pelvic abscesses is less well-dened. By denition, these patients have more severe diverticulitis with a mortality rate of 5% to 10% and a higher rate of emergency surgery (up to 25%).152 Additional considerations include the success of percutaneous drainage, the ability to access the abscess, the failure rate and potential complications of percutaneous drainage, and the ultimate outcome. Assessing outcome should include a reasonable follow-up period with assessment of ability to perform a resection and primary anastomosis in patients resected and risk of recurrent sepsis in those patients who are observed. The initial approach to patients with diverticular abscess includes bowel rest, antibiotics, and close observation. Several possible antibiotic regimens may be employed. Antibiotics are targeted to cover gastrointestinal ora. Small abscesses, particularly in a stable patient without signs of systemic sepsis, do not require percutaneous drainage. In several reports, small abscesses (which were dened as those between 2 and 4 cm) often resolve with intravenous antibiotics alone without the need for operative or percutaneous drainage.17,153-155 For those patients with diverticular abscess who continue with signs of sepsis (fever, abdominal pain, and leukocytosis), percutaneous drainage is preferred. A recent review suggested that 20% to 30% of diverticular abscesses were amenable to percutaneous drainage and the failure rate of percutaneous drainage was 20% to 30%.155 The preferred approach for percutaneous drainage is usually by a transabdominal route with care to avoid the inferior
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FIG 7. Pigtail catheter in a complex diverticular pelvic abscess.

epigastric or deep circumex iliac vessels156 (Fig 7). If the abscess is not accessible by this route, a transgluteal, transperineal, transvaginal, or transrectal route may be employed. Transabdominal compared with transgluteal or transperineal drains tend to be better tolerated in terms of patient comfort. The success rate with simple unilocular abscesses is up to 80%, whereas more complex abscesses associated with loculations, stula, or whose drainage route transverses normal organs are associated with a higher failure rate.156 The expertise and skill of the interventional radiologist is also associated with a higher success rate. The location of abscess inuences the chance of success with antibiotics and/or percutaneous drainage. In general, mesocolic or pericolic abscesses have a better prognosis than pelvic or retroperitoneal abscesses.157,158 Pericolic abscesses may result from earlier disease and local inammatory changes with abscess formation in the mesentery, whereas pelvic abscesses may result from larger perforation with the potential to extend from the mesentery to the surrounding pelvis and peritoneum. In a study of 73 cases of diverticular abscess, 59% of cases eventually required surgery, while 71% of patients with pelvic abscess required resection.157 Both size and location inuence the success rate of percutaneous drainage. One study suggested that the size of an abscess did not determine the outcome and patients who were managed medically had an identical outcome to those who underwent drainage159; however, most studies suggest that abscesses of up to 4 cm can be optimally managed by antibiotics.149,153-155 The use of antibiotics alone versus percutaneous drainage and antibiotics was compared in 1 retrospective study of patients with
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diverticulitis and CT-conrmed abscesses.149 The outcome of patients treated with antibiotics alone was equivalent to patients treated with drainage and antibiotics. The failure rate of percutaneous drainage was 33%. Patients who underwent percutaneous drainage had larger abscesses and the study was not randomized; however, more than 80% of patients with Hinchey stage II abscesses could be treated successfully with antibiotics. In conclusion, approximately 15% of patients with diverticulitis have an associated pericolic or pelvic abscess. Antibiotics remain the mainstay of treatment, with percutaneous drainage reserved for larger abscesses with a radiologic window. The decision for surgery should be approached on a case-by-case basis. Diverticulitis associated with abscess denotes more severe diverticulitis and a substantial number of patients require sigmoid resection. Although 40% to 50% of patients admitted with diverticular abscesses respond to conservative treatment, sigmoid resection is recommended for selected patients, particularly those with more complex or larger abscesses and those with recurrent or persistent symptoms.157 Ideally, elective surgery is performed after initial treatment with antibiotics and/or percutaneous drainage as indicated.

Perforated Diverticulitis
Approximately 1% of patients with diverticulitis develop free perforation, which may include purulent or fecal peritonitis (Fig 1B). Free perforation almost exclusively develops on the rst attack of diverticulitis and is generally not seen in patients who have had multiple attacks of diverticulitis. The mainstay of treatment for perforated diverticulitis over the last several decades has been the Hartmann procedure, which resects the disease and eliminates the septic focus. A disadvantage of the procedure is the requirement for a second major surgical procedure to reverse the colostomy and the attendant morbidity and potential mortality of the procedure. Data from large administrative databases suggest that at least one third of patients may never undergo reversal160 and up to 70% of patients older than 77 years may not undergo reversal.161 Women are less likely than men to undergo Hartmann reversal.160,162 The development of a scoring system may assist clinicians in identifying factors predictive of colostomy reversal.163 There has been renewed interest in performing resection and primary anastomosis in selected patients with Hinchey III and Hinchey IV diverticulitis. Several systematic reviews and meta-analyses have suggested that primary anastomosis is superior to Hartmann resection for
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patients with perforated diverticulitis; however, there is considerable selection bias.133,164 In clinical practice, the decision to perform a primary anastomosis should be made on a case-by-case basis. Several technical and patient-related factors must be considered by the surgeon to determine if the patient is a good candidate for a primary anastomosis. Hemodynamic instability, diffuse peritonitis (either purulent or fecal), ischemia, or signicant edema of the bowel at an intended site of anastomosis and anemia, malnutrition, and immunocompromised state are general contraindications to a primary anastomosis.165 Although discussed frequently in the literature, data from the Nationwide Inpatient Sample have not shown any evidence that primary anastomosis is being more commonly used as the preferred procedure for patients who undergo surgery for acute diverticulitis.23 Recently, alternatives to resection and denitive treatment with laparoscopic lavage have been reported. Based on a small series of successful laparoscopic lavage for treatment of patients with perforated diverticulitis with purulent peritonitis,166 a prospective multi-institutional study of 100 patients has been reported.9 Patients with perforated diverticulitis and generalized peritonitis underwent laparoscopic lavage as denitive treatment. No effort was made to mobilize and resect the sigmoid colon. The median age was 62.5 years with a follow-up of 36 months. Eight patients were found to have fecal peritonitis and converted to an open procedure and underwent resection. The remaining 92 patients were treated successfully with laparoscopic lavage with a 4% morbidity rate and a 3% mortality rate. Two patients later required intervention for a pelvic abscess and 2 patients presented with recurrent diverticulitis in the study period. These data challenge our conventional surgical teaching and suggest that selected patients with purulent peritonitis from diverticulitis may be treated successfully with laparoscopic lavage without resection of the affected segment of colon. A subsequent review of 8 studies of 213 patients with acute complicated diverticulitis managed by laparoscopic lavage has noted a 3% conversion rate. Ten percent of patients had complications and, during a mean follow-up of 38 months, 38% of patients underwent elective sigmoid resection with primary anastomosis.8 In the future, this modality may become the preferred treatment for perforated peritonitis with associated purulent peritonitis. Additional concerns include whether many of these patients required any operative intervention or whether antibiotics, bowel rest, and drainage by interventional radiology techniques would have achieved the same outcome.
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TABLE 5. Diverticular stulas Coloappendiceal Colocolonic Colocutaneous Coloenteric Colouterine Colovenous Cologastric Coloperineal Coloperianal Coloureteral Colovaginal Colovesical Colovesicovaginal

Fistulas
Fistulas occur in 2% of patients with diverticular disease.1 The localized inammatory process develops into an abscess, which then decompresses into adjacent viscera (Table 5). Patients who develop stulas generally do not need emergent intervention as the abscess has decompressed; in fact, many patients with stulas may have few abdominal signs and symptoms. Colovesical stulas are the most common (65%), followed by other types of stulas including colovaginal, coloenteric, colouterine, and colocutaneous stulas.167-170 Colovesical Fistulas. Colovesical stulas are more common in men than in women. Women affected with a colovesical stula have usually undergone a prior hysterectomy. Patients often present with prominent urinary symptoms including polymicrobial urinary tract infections, pneumaturia, and fecaluria. CT scanning reveals air and/or contrast in the bladder in the absence of prior instrumentation (Fig 8). If performed, cystoscopy shows inammation generally at the dome of the bladder and, on occasion, vegetable material in the urine. Colovesical stulas may also be associated with locally advanced bladder or primary colon cancer, and cystoscopy and colonoscopy may be more effective tests to exclude malignancy than CT scanning. Imaging is more helpful to determine the etiology of a stula than to document the stula itself. The surgical principles for treatment of colovesical stulas due to diverticular disease include resection of the affected segment (generally the sigmoid colon) and pinching off the stula. The stula is generally small and may be suture repaired. Ureteral stents are generally not needed. In some cases, the precise site of the stula cannot be determined, and pinching it off is sufcient treatment; sutures are not absolutely necessary. A primary
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FIG 8. (A) Arrow points to colovesical stula. (B) Inamed sigmoid colon adjacent to stula. (C) Air
in noncatheterized bladder consistent with colovesical stula.

anastomosis can usually be performed safely. Omentum is used to interpose between the anastomosis and the bladder. On occasion, nonoperative management is used for colovesical stulas, especially if the symptoms are minor and the patient has medical comorbidities conferring a signicant operative risk. Suppressive antibiotics may be used to ameliorate symptoms in such cases.171 Colovaginal Fistulas. Colovaginal stulas occur almost exclusively in women who have undergone a prior hysterectomy (Fig 9). Signs and symptoms include vaginal discharge and passage of air per vagina. Often, women have seen a gynecologist initially for evaluation of vaginal discharge. A single-stage sigmoid resection can generally be performed, pinching off the site of the stula and interposing omentum. Colocutaneous Fistula. Colocutaneous stulas rarely occur de novo and are generally seen in patients who have undergone prior colectomy or percutaneous drainage.172 Risk factors for the development of colocutaCurr Probl Surg, September 2010 711

FIG 9. Colovaginal stula. Arrow demonstrates vaginal lling with contrast from pericolonic abscess.

FIG 10. Large sigmoid phlegmon causing a large bowel obstruction. Arrow shows a retrograde
injection of contrast within the rectum, which is unable to pass the obstruction.

neous stula include unsuspected Crohns disease and anastomosis to the distal sigmoid colon and not the proximal rectum. Diverticular Stricture/Obstruction. Repeated attacks of diverticulitis may be associated with the development of a sigmoid stricture and progressive obstructive symptoms. Less commonly, complete large bowel obstruction associated with diverticular disease develops (Fig 10). The major differential diagnosis is with obstructing colon cancer. Although large bowel obstruction is most commonly associated with obstructing
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colon cancer, approximately 10% of large bowel obstructions are attributable to diverticular disease.173 Colonic stricturing typically develops after several recurrent attacks leading to brosis with the colonic wall. Small bowel can also become adherent to a focus of inamed colonic tissue, leading to associated small bowel obstruction. The approach to management depends on whether the obstruction is complete or partial. Patients with a partial obstruction that resolves with bowel rest, intravenous hydration, and antibiotics may be able to undergo elective resection. In some patients, treating the acute inammatory phlegmon allows for resolution of the obstruction. Endoscopic or radiologic evaluation can then be performed and elective resection planned. For patients with complete obstruction, there are a number of surgical options. In the past, persistence of obstruction after treatment with antibiotics typically required sigmoid resection, end colostomy, and Hartmann closure of the rectum because of concern about the increased risk of anastomotic leakage in patients who had dilated and edematous bowel or who were not able to undergo preoperative mechanical bowel preparation. Although the Hartmann resection is still an excellent option in selected patients, other options include sigmoid resection with primary anastomosis and diverting proximal stoma (usually a loop ileostomy), on table lavage and primary anastomosis, or colonic stent placement followed by semielective sigmoid resection. On-table lavage is a technique that allows for cleansing of the fecal laden, obstructed colon before potential anastomosis. The technique has been described by Murray and colleagues174 and involves mobilization of the splenic exure and at times the hepatic exure. A Foley catheter attached to warm irrigation uid is introduced through the appendix. If surgically absent, the catheter may be placed through a cecotomy or ileostomy. Corrugated anesthesia tubing is placed through the distal colon and secured with umbilical tape. The colon is lavaged until the returns are clear. The technique may be used in selected patients who are hemodynamically stable and in whom there is minimal contamination. Although the need for mechanical bowel preparation has been called into question for elective colon resection, this claim has not been critically evaluated in patients with bowel obstruction.175 Lee and colleagues described the use of on-table lavage and sigmoid resection with primary anastomosis in 33 patients with diverticular disease who underwent nonelective resection. There were no anastomotic leaks in this series, but there was a signicant (18%) incidence of wound infection.176 Several authors have demonstrated that treatment of acute colonic obstruction with self-expanding metal stents is a viable option, particuCurr Probl Surg, September 2010 713

larly in patients with obstructing colon cancer.177,178 Colonic stenting for benign obstructions is associated with a high rate of stent migration as well as other delayed complications. In a series of 104 procedures from 1 center, 8 patients had obstruction from a benign etiology.179 After colonic stenting, many required reinterventions and only 3 patients achieved a benet from stenting. From a technical standpoint, stenting a diverticular stricture which is potentially longer or more angulated may be more difcult than stenting a short segment stricture from colon cancer. Colonic stenting in benign disease remains a controversial procedure and should be embarked on with caution.180-182 Diverticular Hemorrhage. Diverticular hemorrhage is the most common form of lower gastrointestinal hemorrhage and is responsible for 30% to 40% of episodes of lower gastrointestinal hemorrhage.183 It does not typically occur in association with acute diverticulitis. Most diverticular bleeding is typically painless but often manifests with signs and symptoms of hemodynamic instability. Diverticula represent herniation of the colonic wall at sites where vasa recta penetrate the colonic wall. The vasa recta are subject to sheer forces as they are draped over the diverticulum. This makes them susceptible to disruption and bleeding. Inammation does not play a role in this process. Because the right colon is thin walled, diverticular bleeding tends to occur more frequently in the ascending colon.184 Blood loss can be massive in up to 20% patients presenting with diverticular hemorrhage.185,186 All patients presenting with symptoms suggestive of this diagnosis should have adequate intravenous access and hemodynamic monitoring. Patients should be fully resuscitated with intravenous uid and blood products if necessary. Diagnostic evaluation begins with nasogastric tube lavage and bedside proctoscopy. These maneuvers easily exclude upper gastrointestinal and hemorrhoidal bleeding as potential sources. While resuscitation continues, it is imperative to make attempts to localize the bleeding source. Following a full mechanical bowel preparation, patients should be evaluated with optical colonoscopy. Colonoscopy is the preferred initial test because it can localize bleeding but also excludes other sources of hemorrhage such as carcinoma. There are small case series describing successful endoscopic intervention for the management of diverticular bleeding including injection of epinephrine, cautery, and placement of clips.187-189 If colonoscopy has not successfully identied a bleeding site, a technetium99-labeled red blood cell scan should be the next study. This nuclear medicine study has several advantages. If there is active bleeding,
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then the nuclear scan will demonstrate extravasation of the radiolabeled red blood cells into the lumen of the colon. One advantage of radiolabeled red blood cells is that they circulate for 48 hours, allowing for repetition of the scan if there are repeated bleeding episodes. In addition, this study can detect bleeding at rates as low as 0.1 mL/min.190 Sulfur colloid can also be labeled with technetium but has a very short half-life and therefore is not useful for the detection of intermittent bleeding. Mesenteric angiography involves the selective catheterization of the superior and inferior mesenteric arteries and their tributaries. Extravasation of contrast in the lumen of the colon is diagnostic. Mesenteric angiography can typically detect bleeding rates of 1 to 3 mL/min. If bleeding is detected, the procedure is potentially therapeutic as coils or foam can be injected in an attempt to thrombose the bleeding vessel and control bleeding.191,192 A catheter can also be left in place for administration of vasopressin or to assist the surgeon in identication of the bleeding site. Surgical intervention is seldom necessary as bleeding is self-limited in greater than 80% of cases.193 Indications for surgical resection include persistent transfusion requirements, hemodynamic instability, or recurrent hemorrhage. If a bleeding site is localized, then segmental colectomy is the preferred surgical procedure. It should be noted that even when bleeding is localized preoperatively, segmental resection is associated with a rebleeding rate of 14%.194 In patients in whom a bleeding site has not been localized, subtotal colectomy is suggested; however, this is associated with a high degree of morbidity and mortality.195,196

Operative Therapy
Elective Management
Open sigmoid resection is generally performed through a midline incision. Preoperative mechanical bowel preparation is not necessary but is often performed.175 Preoperative intravenous antibiotics are administered. The sigmoid colon is mobilized and proximal and distal points selected for resection. The proximal resection margin should be in soft pliable bowel and it is not necessary to resect all proximal diverticula. The distal resection margin is the proximal rectum since anastomosis to the distal sigmoid is associated with a higher risk of recurrent diverticulitis.197,198 It may be necessary to mobilize the splenic exure to perform a tension-free anastomosis; alternatively, rectal mobilization will also afford additional length. One study suggested that an inframesenteric dissection with preservation of the inferior mesenteric artery decreased
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the incidence of anastomotic leak.199 A hand-sewn or stapled anastomosis is performed. The anastomosis is most often performed with an end to end anastomosis stapler. In cases of stulas to the bladder or the vagina, the stula may be simply pinched off and a resection of bladder and/or vagina is not necessary. Once a stula is pinched off, omentum can be used to interpose between the bladder and/or vagina and the colon. Ureteral stents are generally not necessary but may be used in selected cases. Although they do not prevent ureteral injuries, they permit easy recognition and repair of such injuries.200 A technique that may be helpful in mobilization includes proximal to distal resection in which the colon is divided proximal to the phlegmon with a linear stapler, and the colon is dissected proximal to distal, rather than performing a lateral to medical dissection.201 This technique may facilitate easier identication of the ureter and avoid injury. Although the rectum is not primarily involved with diverticulitis, inammation of the proximal rectum may be encountered from the diverticular phlegmon or from an associated pelvic abscess or diverticular perforation. In such cases, based on sound surgical judgment and specic intraoperative factors, primary anastomosis potentially to the mid rectum with proximal fecal diversion may be performed.

Minimally Invasive Colectomy


The advent of laparoscopic surgery has ushered in a new era in the surgical management of diverticular disease. In the last decade, increasing numbers of resections for diverticular disease have been performed laparoscopically. Conventional laparoscopic techniques allow the surgeon to perform all the major portions of the case, including the anastomosis, through small 5- or 12-mm trocars (Fig 9). A commonly practiced technique involves the use of a hand-assisted technique. In this type of approach the surgeons hand is placed into the abdomen through a small vertical lower midline or Pfannensteil incision to assist in the mobilization of the colon. The dissection can be carried out in a medial to lateral or lateral to medial approach. In the medial to lateral approach a plane is made below the inferior mesenteric artery. The ureter, gonadal vessels, and other retroperitoneal structures are swept away. The inferior mesenteric artery is then divided using a stapler or energy device. The sigmoid colon can then be mobilized up to the level of the splenic exure by sweeping down the attachments of the left colonic mesocolon to Gerotas fascia and retroperitoneum. It may be necessary to mobilize the splenic exure to perform a tension-free
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TABLE 6. Conversion rates in selected laparoscopic colectomy series Author Klarenbeek et al233 Jones et al215 Cole et al234 Hassan et al235 Belizon et al236 Chang et al203 Schwandner et al208 Bouillot et al237 Trebuchet et al238 Vargas et al205 Burgel et al239 Siriser240 Berthou et al241 Kckerling et al242 Smadja et al243 Stevenson et al244 Year 2009 2008 2008 2007 2006 2005 2004 2002 2002 2000 2000 1999 1999 1999 1999 1998 Patients 52 500 151 91 143 85 396 179 170 69 56 65 110 304 54 100 Conversion rate 19.23% 2.80% 12.58% 26.40% 19.58% 7.28% 6.82% 13.97% 4.12% 26.09% 14.29% 4.62% 8.18% 7.24% 9.26% 8.00%

anastomosis and there is evidence that suggests that the incidence of splenic injury is lower with a laparoscopic approach.202 Proximal and distal resection margins can then be chosen. A hand-sewn or stapled anastomosis is performed. The anastomosis can be performed in intracorporeal fashion. Alternatively, the anastomosis can be fashioned through the specimen-extraction site. Use of the extraction site in cases of stulas or abscesses often allows the laparoscopic completion of colectomies in patients with severe disease without conversion. Nonetheless, there are a wide range of published conversion rates (Table 6). In the conventional or straight laparoscopic technique the essential elements of the operation remain the same. The colon can be mobilized from a lateral to medial or medial to lateral approach. The specimen is typically extracted through a periumbilical vertical incision and the anastomosis performed in an intracorporeal fashion. Prospective evaluation of hand-assisted laparoscopic techniques demonstrates that, although operative times are similar to conventional laparoscopic surgery, conversions are less frequent (0% vs 13%).203 Other groups have demonstrated that the colon can be removed through the vagina, thereby obviating the need for any incisions other than the trocar sites.204 Minimally invasive colectomy has several benets. The Norfolk Surgical group demonstrated that ileus and length of stay were less in patients who had their sigmoid colectomy completed laparoscopically.205 Other authors have demonstrated decreased postoperative pain, wound infection rates, operative blood loss, transfusions, and a faster return to preoperative
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activity levels.206,207 The surgical outcomes of 676 patients undergoing laparoscopic colectomy for diverticulitis were compared to the outcomes of those undergoing laparoscopic colectomy for nondiverticular disease. No differences were noted when comparing complications, mortality, length of stay, or oral feeding.208

Urgent and Emergent Procedures


Although the goal of surgery for diverticular disease is to perform a single-stage resection with a primary anastomosis, a substantial number of patients present emergently or require urgent intervention. The emergency surgical management of diverticular disease has undergone substantial evolution in the past several decades. In the early midtwentieth century, a 3-stage procedure was advocated. Initially, sepsis was controlled by drainage and a defunctioning, generally transverse, loop colostomy. The diseased segment was subsequently excised at the next stage and the nal stage consisted of colostomy reversal. With this approach, the mortality rate approached 25%; the septic focus was left in place at the initial procedure, and a number of patients failed to progress through all 3 stages and remained with a colostomy, which although intended to be temporary, remained in place.209 The Hartmann procedure subsequently became the procedure of choice as it appeared to reduce the operative mortality by half and had less morbidity and length of hospitalization than the 3-stage procedure.209 In the 1980s and 1990s, the Hartmann procedure was considered the standard of care for emergency surgical management of left colon emergencies.210 The Hartmann procedure resects the diseased segment of bowel, eliminates the septic focus, and allows for restoration of bowel continuity on an elective basis. The patient is approached through a midline laparotomy both to conrm the diagnosis and to assess the degree of contamination and inammation. Preoperative stoma site marking is helpful. The affected sigmoid colon is mobilized and a proximal to distal approach is generally easiest and safest. The bowel can be transected proximally and dissection carried down to the sacral promontory. A wide mesenteric dissection is unnecessary. The ureter should ideally be identied. All diseased and thickened bowel should be resected and the resection margin should ideally be the proximal rectum. Alternatively, distal sigmoid, if not inamed, can be left in place for later resection at the intended Hartmann reversal. The proximal rectum is transected with a stapler or oversewn depending on individual preference. The stoma is brought out on the left side; splenic exure mobilization may be necessary to achieve adequate length particularly if there is signicant foreshortening of the mesentery from the diverticular
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phlegmon. The colostomy is generally left in place for at least 3 months, allowing the patient to sufciently heal and hopefully facilitate identication of the Hartmann stump. Waiting longer can make identication of the Hartmann stump difcult due to brosis.211 There are several drawbacks to the Hartmann procedure. Up to 35% of patients may never undergo colostomy reversal.160 In a systematic review of 1051 patients in 54 studies, the mortality associated with the Hartmanns procedure was 18.8%; the wound infection rate was 24.2%, and stoma complications occurred in 10.3%.161 In view of these considerations, there has been renewed interest in examining the role of primary resection and anastomosis without diversion for nonelective surgery for diverticular disease. A review noted a mortality rate of 9.6% vs 15.1% for patients undergoing primary anastomosis vs Hartmanns resection for perforated diverticulitis.212 Although the patients were matched for American Society of Anesthesiologists grade, the retrospective data and the degree of selection bias limit the ability to make clinically sound conclusions about which patients can safely undergo primary resection and anastomosis in the nonelective setting. In addition, the use of Hinchey staging only to stratify severity of diverticulitis may omit several other important clinical parameters. The Cleveland Clinic Diverticular Disease Propensity Score has been used to identify factors based on patient presentation and degree of intra-abdominal contamination, which can provide a risk estimate for nonrestorative resection in patients undergoing surgery for diverticular disease. Factors predicting a Hartmanns resection vs resection with primary anastomosis included BMI greater than 30, Mannheim peritonitis index greater than 10, and Hinchey stage greater than 2.213 Selection of patients who may safely undergo resection and primary anastomosis in the acute setting requires considerable judgment and must consider patient-related and disease-related factors. Primary anastomosis is not advisable for patients with hemodynamic instability, diffuse fecal or purulent peritonitis, immunocompromised patients, or those with severe anemia or malnutrition, and those with ischemia or edema of the bowel at the proposed site of anastomosis.165 Despite systematic reviews and a focus in the literature on performing primary anastomosis in the nonelective patient, a recent review of 267,000 patients admitted with acute diverticulitis and 33,5000 patients (from 1998 to 2005) who underwent operation electively for diverticulitis found no evidence that primary anastomosis was more commonly performed.23 Because formation of an end stoma and Hartmanns procedure are associated with high rates of morbidity and mortality, several authors have attempted to manage acute diverticulitis with laparoscopic lavage.
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Recently, alternatives to resection and denitive treatment with laparoscopic lavage have been reported. Myers and colleagues reported on a prospective multi-institutional study of 100 patients.9 Patients were not routinely evaluated with initial CT. Patients with perforated diverticulitis and generalized peritonitis underwent laparoscopic lavage as denitive treatment. No effort was made to mobilize and resect the sigmoid colon. The median age was 62.5 years with a follow-up of 36 months. Eight patients were found to have fecal peritonitis and converted to an open procedure and underwent resection. The remaining 92 patients were treated successfully with laparoscopic lavage with a 4% mortality rate and a 35% morbidity rate. Two patients later required intervention for a pelvic abscess and 2 patients presented with recurrent diverticulitis in the study period. A subsequent review of 8 studies of 213 patients with acute complicated diverticulitis managed by laparoscopic lavage has noted a 3% conversion rate. Ten percent of patients had complications and, during a mean follow-up of 38 months, 38% of patients underwent elective sigmoid resection with primary anastomosis.8

Minimally Invasive Colectomy for Complicated Disease


As laparoscopic colectomy has gained widespread use, this technique has been applied to patients with complicated diverticular disease. Martel and colleagues compared the outcomes of laparoscopic colectomy following treatment of complicated and uncomplicated disease in 183 patients. These authors demonstrated no difference in anastomotic leak rates and intraoperative complications. It should be noted, however, that patients with complicated disease underwent conversion to open procedures more frequently (23% vs 4%).214 Although overall conversion rates differ among studies, higher rates of conversion in patients with complicated diverticulitis are noted in a number of series on this topic.205,215,216 Some studies have noted that when complicated disease is restricted to stula or abscess, then there is no increased risk of conversion when comparing patients with complicated and uncomplicated disease.151,217,218 A Chinese group has shown that laparoscopy is feasible in the management of complicated right-sided diverticulitis. Although patients in the laparoscopic group recovered bowel function more quickly (3.5 vs 5 days), the length of stay in both groups was similar.219

Special Situations
Recurrent Diverticulitis
Recurrent diverticulitis following resection is uncommon. In the patient presenting with abdominal pain following resection for diverticulitis, a
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systematic evaluation should be performed to exclude other causes of pain. Etiologies such as inammatory bowel disease, ischemic colitis, colorectal cancer, adhesive disease, gynecologic pathology, and irritable bowel syndrome should be considered. Patients with diverticular disease have signicant overlap with irritable bowel syndrome. Additional pathology review of the resected segment of sigmoid colon may be helpful. Patients who present with recurrent diverticulitis may not have had diverticulitis (but only diverticulosis) on initial resection. The development of recurrent diverticulitis should be distinguished from persistent poorly characterized abdominal pain following resection. Munson and colleagues found that 27.2% of patients following resection for diverticular disease continued to have pain.220 Parks and Connell noted persistence of mild symptoms in 24% of patients who underwent a 3-stage resection for diverticulitis.38 The most established risk factor for recurrent diverticulitis following resection is the level of anastomosis. Although diverticulitis may only involve a portion of the sigmoid colon, the entire sigmoid should be resected and anastomosis performed to the proximal rectum. The rectum is identied at the level at which the tenia fan out, which is generally around the sacral promontory. The proximal resection margin is less well-established and the dictum has been to anastomose in soft pliable bowel.17 It is unnecessary to remove all diverticula of the colon, but the anastomosis should be performed in an area that is free of diverticula. Two studies have looked at the level of anastomosis and the risk of recurrent diverticulitis. Benn and colleagues examined 501 patients undergoing sigmoid resection for diverticular disease.197 The incidence of recurrent diverticulitis was 6.7% with anastomosis to the proximal rectum compared with 12.5% in patients who underwent anastomosis to the distal sigmoid colon. Thaler and colleagues also noted the level of anastomosis was the only predictor of recurrence in regression analysis with patients with a colosigmoid anastomosis having a 4 times higher risk of recurrence compared with patients with a colorectal anastomosis.198

Giant Colonic Diverticulum


The condition of giant colonic diverticulum is rare and was rst reported by Bonvin and Bonte in 1946.221 Less than 150 cases have been reported in the literature.222 These diverticula affect men and women equally and are most commonly found in the sigmoid colon. The average diameter is 13 cm but diverticula as large as 40 cm have been reported. Two theories have been put forth for development of giant diverticula; 1 proposed theory is that the diverticulum becomes massive because of a
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ball-valve mechanism allowing air into but not out of the diverticulum.223 Another theory suggests that air is trapped into the diverticulum because of gas forming micro-organisms without obstruction at the neck of the diverticulum. Many patients with this entity are minimally symptomatic or present with mild episodes of pain. On abdominal palpation, a soft mobile mass may be appreciated. The differential diagnosis includes colonic duplication, pancreatic pseudocyst, Meckels diverticulum or jejunal diverticulum, sigmoid volvulus, or emphysematous cholecystitis. More commonly, the abnormality is noted on abdominal CT scan. Treatment consists of sigmoid resection with anastomosis. Diverticulectomy, which was has been employed in earlier reports, is rarely performed today.

Diverticulitis---Other Sites
Right Colonic Diverticulitis. Right-sided diverticulitis is rare in Western countries and more common in the Far East.224 Cecal diverticula are of 2 types, both true and false. True diverticula contain all layers of the bowel wall and are usually congenital and tend to be solitary. Acquired diverticula of the cecum are false, containing mucosa and muscularis mucosa, tend to be multiple, and tend to be associated with diverticula elsewhere in the colon. Patients with cecal diverticulitis present at a younger age than the average patient with sigmoid diverticulitis. The main differential diagnosis is that of acute appendicitis and it may be difcult in the patient with right-sided abdominal pain, fever, and leukocytosis to distinguish cecal diverticulitis from acute appendicitis. Other differential diagnoses include chronic cholecystitis, mesenteric adenitis, ischemic colitis, pelvic inammatory disease, pancreatitis, Meckels diverticulitis, pyelonephritis, and sigmoid diverticulitis (with a redundant sigmoid loop). Laparoscopy is sometimes helpful to distinguish between cecal diverticulitis and appendicitis. A retrospective review of 49 patients at a single institution found the ratio of acute appendicitis to cecal diverticulitis to be 150:1.225 In the absence of peritoneal signs, patients may be treated with antibiotics. For those patients with repeated attacks or complications including perforation or abscess, resection is indicated. Fang and coworkers reviewed 85 patients treated for cecal diverticulitis.226 Less than 40% were treated with antibiotics and bowel rest. Sixty-seven patients ultimately underwent laparotomy. In the 47 patients with a preoperative diagnosis of appendicitis, 24 underwent appendectomy, 9 underwent diverticulectomy, and 14 underwent right colectomy. In the 20 patients with a preoperative diagnosis of diverticulitis, all underwent right colectomy. Thorson and Ternent227 have suggested a
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TABLE 7. Cecal diverticulitis classication system Grade Grade Grade Grade I II III IV Easily recognizable projecting inamed cecal diverticulum Inamed cecal mass Localized abscess or stula Free perforation or ruptured abscess with diffuse peritonitis

grading system to aid with management of cecal diverticulitis (Table 7). These authors suggested that when diagnosis is uncertain, then right colectomy is most likely the best option.227 With renements in technology and with the widespread use of CT scanning for evaluation of patients with abdominal pain, proceeding to laparotomy or laparoscopy without a relatively secure diagnosis is uncommon. Rectal Diverticulitis. Rectal diverticula are rare, are typically solitary, and are true diverticula including all layers of the bowel wall.60 Transverse Colonic Diverticulitis. Diverticulitis involving the transverse colon is exceedingly rare, with fewer than 50 cases reported, and is often confused with other conditions such as appendicitis or cholecystitis.228 In a large series of 951 patients who all underwent CT scan on initial presentation of diverticulitis, Hall and colleagues found that the prevalence of transverse colon diverticulitis was 2.6%.62

Immunocompromised Patients
Immunocompromised patients include patients receiving systemic steroids, patients with diabetes mellitus or renal failure, transplant patients who are immunosuppressed, patients with cirrhosis, patients with underlying malignancy, and patients being treated with chemotherapy. Patients who are immunosuppressed are more likely to present with free perforation, presumably because of the inability to mount an inammatory response and wall off the infection and are therefore more likely to require emergency surgery with resultant increased postoperative morbidity and mortality. In a combined series of patients who were immunocompromised who presented with diverticulitis, 40% had free perforation, 60% required emergency operation, and the overall postoperative morbidity and mortality rates were 65% and 40%, respectively.229-232 Immunocompromised patients who present with acute diverticulitis and require emergent laparotomy should undergo resection with colostomy and should not undergo primary anastomosis because of the impaired immune system and impaired healing.
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