Professional Documents
Culture Documents
Copia de Diverticulitis
Copia de Diverticulitis
DIVERTICULAR DISEASE
John P. Welch, MD, FACS, and Jeffrey L. Cohen, MD, FACS, FASCRS*
Diverticula are small (0.5 to 1.0 cm in diameter) outpouch- Consequently, as the population of the United States contin-
ings of the colon that occur in rows at sites of vascular ues to age, the overall risk of diverticular complications
penetration between the single mesenteric taenia and one of continues to increase. Before the 20th century, diverticular
the antimesenteric taeniae. At the sites of most diverticula, disease was rare in the United States. By 1996, however,
the muscular layer is absent [see Figure 1]. Technically, such 131,000 patients were being admitted to hospitals with
lesions are really pseudodiverticula; true diverticula (which diverticulitis each year.3 Hospitalizations with this diagnosis
are much less common than pseudodiverticula) involve are increasing, especially in young patients.4
all layers of the bowel wall. Nevertheless, both pseudo- A diet containing refined carbohydrates and low-fiber
diverticula and true diverticula are generally referred to as substances, such as is currently widespread in many devel-
diverticula. oped countries (especially in the West), has been associated
The sigmoid colon is the most common site of diverticula: with the emergence of this disease entity. A low-residue diet
in 90% of patients with diverticulosis, the sigmoid colon is facilitates the development of constipation, which can lead
involved.1 If a diverticulum becomes inflamed as a result to increased intraluminal pressure in the large bowel. In
of obstruction by feces or hardened mucus or of mucosal addition, elevated elastin levels are commonly noted at
erosion, a localized perforation (microperforation) may colon wall sites containing diverticula,5 and this change
occur—a process known as diverticulitis. The incidence of causes shortening of the taeniae.1 High-pressure zones or
diverticulitis has been estimated to be about 10 to 25% in areas of segmentation may develop [see Figure 2], usually in
patients with colonic diverticula.1 Limited prospective data the sigmoid colon, and diverticula begin to protrude at these
suggest that the risk of developing diverticulitis is low in locations.6 If microperforation of a thin-walled diverticulum
patients with symptomatic diverticulosis.2 Both diverticulo- takes place, local or, uncommonly, widespread contamina-
sis and variants of diverticulitis may be subsumed under the tion with fecal organisms may ensue. The pericolic tissue
more encompassing term diverticular disease. (typically, the mesentery and the pericolic fat) thus becomes
The incidence of diverticular disease increases with age. inflamed, whereas the mucosa tends to remain otherwise
Diverticula are quite common in elderly patients, being normal, with some peridiverticular inflammation.7
present in more than 80% of patients older than 85 years. Several factors appear to promote the development of
diverticular disease and its complications, including the
summer season in the United States,8 decreased physical
activity,9,10 obesity,10–12 intake of nonsteroidal antiinflamma-
Vascular Diverticulum tory drugs (NSAIDs),13,14 smoking,15,16 and constipation from
Structure any cause (e.g., diet or medications). The well-known West-
ern afflictions cholelithiasis, diverticulosis, and hiatal hernia
frequently occur together (the Saint triad). Obesity has been
Antimesenteric
Taenia
Mesenteric
Taenia
Antimesenteric
Epiploic Intertaenial Area
Appendage
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History
Physical examination
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Clinical Evaluation
history
Uncomplicated
(Simple) Diverticulitis
The classic symptoms
of uncomplicated acute
diverticulitis are left
lower quadrant abdomi-
nal pain, a low-grade
fever, irregular bowel
habits, and, possibly,
urinary symptoms if the affected colon is adjacent to the
bladder. If the sigmoid colon is highly redundant, pain may
be greatest in the right lower quadrant. Diarrhea or consti-
pation may occur, together with rectal urgency. Vomiting
is not characteristic, and there may have been previous
episodes.20 In the clinical setting, it may be difficult to make
an accurate diagnosis without imaging studies.21
The differential diagnoses are listed here [see Table 1].22 Figure 3 Barium enema shows a napkin-ring carcinoma (arrow) in
Chronic diarrhea, multiple areas of colon involvement, peri- the middle of multiple diverticula in a redundant sigmoid colon.
anal disease, perineal or cutaneous fistulas, or extraintestinal
signs are suggestive of Crohn disease. Rectal bleeding should
raise the possibility of inflammatory bowel disease, isch-
emia, or carcinoma; such bleeding is uncommon with diver- despite the low incidence of diverticula in this segment of
ticulitis alone. Given the prevalence of diverticula, it is the colon. Patients tend to be elderly and to have cardiovas-
not surprising that colon carcinoma may coexist with diver- cular disease and hypertension. Regular intake of NSAIDs
ticular disease [see Figure 3]. However, diverticulitis does may increase the risk of this complication. Although patients
not appear to increase the risk of developing colorectal may lose 1 to 2 units of blood, the bleeding usually ceases
adenomas or carcinomas.23 spontaneously,27 and expeditious operative treatment is
generally not necessary.
Complicated Diverticulitis The most common form of complicated diverticulitis
Some cases of diverticulitis are classified as complicated, involves the development of a pericolic abscess, typically
meaning that the disease process has progressed to obstruc- signaled by high fever, chills, and lassitude. Such abscesses
tion, extensive phlegmon, abscess, fistula, or free perforation may be small and localized or may extend to more distant
[see Figure 4]. Complicated diverticulitis may be particularly sites (e.g., the pelvis). They may be categorized according to
challenging to manage,24 especially because patients usually the Hinchey classification of diverticular perforations,28 in
have no history of diverticulitis.25 Lower gastrointestinal which stage I refers to a localized pericolic abscess and stage
(GI) bleeding is also a complication of diverticular disease in II to a larger mesenteric abscess spreading toward the pelvis
4 to 48% of cases, and in the United States, 33% of acute [see Figure 5]. On rare occasions, an abscess forms in the ret-
lower GI bleeding is caused by diverticulosis.26 When diver- roperitoneal tissues, subsequently extending to distant sites
ticular hemorrhage occurs, it is usually associated with such as the thigh or the flank. The location of the abscess can
diverticulosis rather than with diverticulitis. Approximately be defined precisely by means of computed tomography
50% of diverticular bleeding originates in the right colon, (CT) with contrast.
Some abscesses rupture into adjacent tissues or viscera,
resulting in the formation of fistulas. Recurrent attacks of
Table 1 Differential Diagnoses of diverticulitis may antecede fistula formation.25 The types
Uncomplicated (Simple) Diverticulitis most commonly seen (50 to 65% of cases) are colovesical
fistulas. This complication is less common in women
Gynecologic and urinary disorders
Perforated colon carcinoma
because of the protection afforded by the uterus. Symptoms
Crohn disease of colovesical fistulas tend to involve the urinary tract (e.g.,
Ischemic colitis pneumaturia, hematuria, and urinary frequency). Fecaluria
Epiploic appendagitis is diagnostic of colovesical or enterovesical fistulas. Colo-
Appendicitis vaginal fistulas (which account for 25% of all diverticular
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gastro diverticular disease — 4
physical
examination
Uncomplicated
Colovesical Diverticulitis
Fistula
Physical examination
reveals localized left
lower quadrant abdomi-
nal tenderness with vari-
able degrees of guarding
and rebound tenderness.
A mass is occasionally
felt. The stool may con-
Figure 4 Major complications of diverticular disease of the sigmoid tain traces of blood, but
colon.231
gross bleeding is unusual. Localized inflammation of the
perforated diverticulum and the adjacent mesentery is pres-
ent, and a phlegmon may be seen as well. Depending on the
fistulas) are usually seen in women who have undergone severity of the physical findings, patients may be managed
hysterectomies. The diseased colon is adherent to the vagi- either as inpatients or outpatients.32
nal cuff. Most commonly, patients complain of a foul vagi-
nal discharge; however, some patients present with stool Complicated Diverticulitis
emanating from the vagina. In a patient with a pericolic abscess, a mass may be detect-
About 10% of colon obstructions are attributable to diver- able on abdominal, rectal, or pelvic examination. In a patient
ticulitis. Acute diverticulitis can cause colonic edema and a with a colovaginal fistula, a site of granulation tissue and
functional obstruction that usually resolves with antibiotic drainage is seen at the apex of the vaginal cuff. When
infusion and bowel rest. Stricture formation is more com- patients develop obstruction, there may be marked abdomi-
mon, usually occurring as a consequence of recurrent attacks nal distention, usually of slow onset; abdominal tenderness
of diverticulitis. Circumferential pericolic fibrosis is noted, may or may not be present, but if tears develop in the cecal
and marked angulation of the pelvic colon with adherence taeniae, right lower quadrant tenderness is typically seen. In
to the pelvic sidewall may be seen. Patients complain of con- a patient with a free perforation, there is marked abdominal
stipation and narrowed stools. Colonoscopy can be difficult tenderness, usually commencing suddenly in the left lower
and potentially dangerous in this setting. Differentiating a quadrant and spreading within hours to the remainder
diverticular stricture from carcinoma may be impossible by of the abdomen. Hypotension and oliguria may develop
any means short of resection. later. Patients with rectal bleeding usually have no com-
The term malignant diverticulitis has been employed to plaints of abdominal pain or tenderness, and they may
describe an extreme form of sigmoid diverticulitis that is be hypovolemic and hypotensive, depending on the rapidity
characterized by an extensive phlegmon and inflammatory of the bleeding.
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Figure 5 The Hinchey classification divides diverticular perforations into four stages. Mortality increases significantly in stages III and IV.28
Investigative Studies may follow extravasation of barium [see Figure 8 and Figure 9].
Furthermore, in the acute setting, only the left colon should
imaging be evaluated. Carcinoma is suggested by an abrupt transi-
The most useful diagnostic imaging study in the setting tion to an abnormal mucosa over a relatively short segment;
of suspected diverticulitis is a CT scan with oral and rectal diverticulitis is usually characterized by a gradual transition
contrast.33 Localized thickening of the bowel wall or inflam-
mation of the adjacent pericolic fat is suggestive of diver-
ticulitis; extraluminal air or fluid collections are sometimes
seen together with diverticula [see Figure 6]. The most
frequent findings (seen in 70 to 100% of cases) are bowel
wall thickening, fat stranding, and diverticula.34 In some
cases, small abscesses in the mesocolon or bowel wall are
not detected. The diagnosis of carcinoma cannot be excluded
definitively when there is thickening of the bowel wall.
Limited studies show that magnetic resonance imaging
has high sensitivity and specificity for acute diverticulitis,
and this technique does not expose the patient to ionizing
radiation.35
Although CT has tended to replace contrast studies in the
evaluation of diverticulitis,34 the latter may be more useful
in differentiating carcinoma from diverticulitis.36 A contrast
study can also be complementary when the CT scan raises
the suspicion of carcinoma [see Figure 7].33 When diverticuli-
tis is suspected, water-soluble contrast material should be Figure 6 Computed tomographic scan showing thickening of the
used instead of barium because of the complications that sigmoid colon (arrow) caused by acute diverticulitis.
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a b
Figure 7 (a) Computed tomographic (CT) scan showing a thickened left colonic wall and diverticulum (arrow). Diverticulitis was considered
the most likely diagnosis. (b) CT scan through an adjacent plane showing deformity of the mucosa, suggesting a possible apple-core lesion
(arrow). Subsequent endoscopy revealed a carcinoma that was obstructing the colon almost completely.
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Management
medical
Uncomplicated diver-
Figure 10 Colonoscopic view of several sigmoid diverticula reveals ticulitis is usually man-
no evidence of active diverticulitis (e.g., edema or narrowing). aged successfully on
an outpatient basis39 by
instituting a liquid or
abnormality.37,38 If diverticular disease is advanced, the low-residue diet and
endoscopic procedure may be difficult; the diverticular administering an oral
segment must be fully traversed for the examiner to be able antibiotic combination
to exclude a neoplasm with confidence. When major lower that covers anaerobes and
GI bleeding occurs, colonoscopy is done to search for gram-negative organisms (e.g., ciprofloxacin or amoxicillin–
polyps, carcinoma, or a site of diverticular bleeding. In the clavulanic acid with metronidazole or clindamycin) over
case of massive bleeding, selective arteriography is useful a period of 4 to 10 days.40 If patients are admitted to the
for localizing the source, and superselective embolization hospital, they usually can be discharged expeditiously on
frequently quells the hemorrhage. The actual risk of bowel oral antibiotics.41,42 A recent randomized trial, however,
ischemia is low when superselective techniques are has shown that antibiotic treatment for acute uncomplicated
employed. Bleeding at the time of arteriography may be diverticulitis neither expedited recovery nor prevented
facilitated by the infusion of heparin or urokinase; however, complications or recurrence.43 Provided that symptoms and
this is a risky approach that should be taken only when signs have subsided, the colon may be evaluated more fully
other attempts at localization have failed and recurrent several weeks later with a contrast study or colonoscopy if
bouts of bleeding have occurred. the diagnosis of diverticular disease has not already been
a
b
Figure 11 (a) Computed tomographic (CT) scan in a patient with a colovesical fistula showing air in the thickened tract (arrow) adjacent to the
sigmoid colon. (b) CT scan through an adjacent plane showing air in the bladder (arrow) as a result of the fistula. No contrast is present in the
bladder.
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established. If symptoms worsen, hospitalization should be the treatment’s effectiveness.50,51 It has been estimated that
considered. Over the long term, patients should be main- 15 to 30% of patients admitted with acute diverticulitis will
tained on a high-fiber diet, although it may take months require surgical treatment during the same admission.1
for the diet to have an effect on symptoms. Limited trials If fever and leukocytosis persist despite antibiotic therapy,
suggest that other substances such as probiotics and antiin- the presence of an abscess should be suspected.52 Small
flammatory agents such as mesalazine may help prevent (< 5 cm) abscesses may respond to antibiotic infusion and
recurrent attacks.44,45 bowel rest. Larger abscesses that are localized and isolated
If more significant physical findings and symptoms of may be accessible to percutaneous drainage [see Figure 13].53
toxicity develop, hospitalization is warranted [see Figure 12]. Generally, this technique is reserved for abscesses greater
Patients are placed on a nihil per os (NPO) regimen, and than 5 cm in diameter in low-risk patients who are not
intravenous fluids and antibiotics are administered (e.g., a immunocompromised. It often leads to resolution of sepsis
third-generation cephalosporin with metronidazole) until and the resulting symptoms and signs (e.g., abdominal pain
abdominal pain and tenderness have resolved and bowel and tenderness and leukocytosis), usually within 72 hours,
function has returned. As a rule, resolution occurs within thereby facilitating subsequent elective surgical resection
several days. If there is clinical evidence of intestinal of the colon. In addition, percutaneous drainage offers cost
obstruction or ileus, a nasogastric tube is placed. In most advantages in that it reduces the number of operative pro-
cases, ileus-related symptoms resolve with antibiotic cedures required and shortens hospital stay.54 Patients with
treatment. CT scans are useful for establishing the correct severe comorbidities at times can be managed with drainage
diagnosis in the emergency department46; furthermore, the alone.55
severity of diverticulitis on CT scans predicts the risk of sub- Access to a pelvic collection may be difficult to obtain, and
sequent medical failure. At times surgical judgment over- the drainage procedure typically must be done with the
rides scan findings: for example, a stable patient with limited patient in a prone or lateral position. If the catheter drainage
pneumoperitoneum can be treated successfully with antibi- amounts to more than 500 mL/day after the first 24 hours, a
otics and supportive treatment.47,48 By observing early trends fistula should be suspected. Before the catheter is removed,
in the leukocyte count and the maximum temperature in a CT scan is done with injection of contrast material through
patients with acute diverticulitis, one can predict whether the tube to determine whether the cavity has collapsed. If
they will recover quickly as expected or if they will likely this approach fails (as it usually does in patients with mul-
require prolonged intravenous antibiotics and/or an opera- tiple or multiloculated abscesses), an expeditious operation
tion.49 Following levels of C-reactive protein may help assess may be necessary.31
Figure 12 Algorithm outlining treatment options for complicated diverticulitis. GI = gastrointestinal; RBC = red blood cell.
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b
a
Figure 13 (a) Computed tomographic scan showing a pericolic abscess (arrow) caused by a contained perforation arising from sigmoid
diverticulitis. (b) A pigtail catheter (arrow) has been placed into the abscess cavity by the interventional radiologist.
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Small bowel obstruction may also complicate the clinical favored strategy, just as with simple sigmoid diverticulitis140;
picture. Mechanical small bowel obstruction may occur as a at times, abscesses can also be treated conservatively.141 In a
consequence of adherence of the small bowel to a focus of Korean series, outpatient treatment was frequently effec-
diverticulitis, especially in the presence of a large pericolic tive.142 In Japan, where right-side diverticulitis also is more
abscess. Whereas small bowel obstruction tends to cause common, medical treatment has been successfully used for
periumbilical, crampy abdominal pain and vomiting, these recurrent attacks of uncomplicated right-side diverticuli-
characteristic manifestations may be obscured in part by tis.143 After a few weeks, colonoscopy should be performed
pain attributed to diverticulitis. The concern in this situation to rule out a colonic neoplasm.
is that ischemic small bowel may be ignored, with poten- If the patient has significant peritonitis or the diagnosis is
tially disastrous consequences. Formation of a fistula into unclear, laparoscopy or laparotomy is indicated. It is impor-
the small bowel should raise the possibility of Crohn dis- tant that one or the other be done because the mortality
ease. CT scanning often helps the surgeon differentiate associated with delayed treatment of perforated cecal diver-
between primary and secondary small bowel obstruction, ticulitis is high. Assuming a reasonable comfort level with
but, ultimately, exploratory surgery may be required for laparoscopic techniques, this is the preferred modality when
both diagnosis and treatment. the diagnosis is uncertain. The ability to evaluate the entire
Lower GI bleeding caused by diverticular disease rarely abdomen is invaluable in this situation. When inflammation
calls for emergency resection because the bleeding is is localized and minimal, colectomy is unnecessary, and
self-limited in most patients (80 to 90%). Furthermore, acute incidental appendectomy should be considered if the cecum
diverticulitis is rare when active bleeding is the presenting is uninvolved at the base of the appendix.144 If desired, the
symptom. Attempts are made to establish the active bleed- diverticulum may be removed as well.
ing site by means of colonoscopy,136 tagged red blood cell Diverticulectomy should be done only under certain con-
nuclear scans, or angiography; barium contrast studies ditions [see Table 3]. Localized diverticulectomy, in general,
have no role to play in this situation. Emergency resection should be reserved for grade I and grade II disease.137,145
is indicated if the bleeding is life-threatening and if colonic Sometimes the ostium of the inflamed diverticulum is pal-
angiography and attempted superselective embolization pable if the cecum is mobilized surgically. On-table cecos-
prove unsuccessful. In an unstable patient, total abdominal copy through the appendiceal stump has also been helpful
colectomy is necessary if the site of bleeding is unknown, in establishing the diagnosis in the operating room.144 Grade
although identification of the bleeding site with intraopera- III and IV cecal diverticulitis may be difficult to differentiate
tive colonoscopy has been reported. In a stable patient with from carcinoma; resection is favored for these lesions. An
ongoing bleeding, repeat angiography at a later time is anastomosis may be created if contamination is limited,
appropriate, or so-called pharmacoangiography (infusion of but, generally, primary resection, ileostomy, and a mucous
heparin) can be employed in an attempt to induce bleeding. fistula are favored for treatment of grade IV disease.
diverticulitis in young patients
Special Types of Diverticulitis Diverticulitis in patients younger than 40 years has been a
focus of considerable attention in the literature, although
cecal diverticulitis
this group represents only about 2 to 5% of the patients
In the United States, diverticulitis rarely involves the in large series.61 The incidence of diverticulitis in young
cecum or the right colon. Right-side diverticula occur in only patients may be increasing, and obese Latino men appear
15% of patients in Western countries, compared with 75% in to be at particular risk.146 This predominance in males may
Singapore.1 The incidence of cecal diverticulitis appears reflect a tendency to underdiagnose acute diverticulitis in
to be related to the number of diverticula present.137 A young women.147 Some authors have asserted that diverticu-
classification system has been proposed that divides cecal litis is particularly virulent in young patients. However, cur-
diverticulitis into four grades [see Figure 16] to facilitate rent data do not support this concept,148 suggesting instead
comparisons between different clinical series and to help that patients with mild diverticulitis are misdiagnosed when
surgeons formulate treatment plans in the operating room.68 hospitalized or are treated as outpatients. The high rate of
Some cecal diverticula are true diverticula, containing all early operation in young patients probably reflects misdiag-
layers of the bowel wall, but the majority are pseudodiver- nosis of diverticulitis as acute appendicitis rather than the
ticula. Diverticulitis of the hepatic flexure and the transverse development of particularly severe forms of diverticulitis.146
colon is even less common and can present with symptoms Unlike elderly patients, hospitalized young patients with
suggesting appendicitis.138 diverticulitis tend to have few comorbidities other than
Patients with right-side disease tend to be younger and obesity.149 Furthermore, young patients hospitalized for
to have less generalized peritonitis than patients with left- diverticulitis tend to have relatively advanced disease,
side diverticulitis.137,138 Because they typically present with perhaps as a consequence of delayed diagnosis, whereas
right lower quadrant pain, fever, and leukocytosis, acute elderly patients hospitalized with an admitting diagnosis
appendicitis is usually suspected. CT scans are helpful for of diverticulitis tend to exhibit a wider spectrum of disease
differentiating cecal diverticulitis from appendicitis or colon severity. Young patients appear not to have a higher rate of
cancer [see Figure 17].139 If cecal diverticulitis is suspected (as recurrent diverticulitis than older patients do; thus, aggres-
in a patient who has previously undergone appendectomy sive resection is not necessary at the time of the first attack.146
or in a patient with known right-side diverticulosis who has However, a finding of advanced diverticulitis on CT scans
experienced similar attacks in the past), medical manage- is a predictor of subsequent disease complications in this
ment with observation and antibiotics is generally the population.75
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gastro diverticular disease — 13
Pus
Pus
Grade IV
Figure 16 Proposed classification of pathologic types of cecal diverticulitis. Grade I is a specific inflamed diverticulum; grade II is a cecal mass;
grade III is characterized by a localized abscess or fistula; and grade IV represents a free perforation or a ruptured abscess with peritonitis.137
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a b
Figure 18 Selected imaging of a 73-year-old patient with perforated diverticulitis. Extensive gas is seen in the left retroperitoneal space (a, b)
and in the left groin (c).
sigmoid colon distal to the anastomosis appears to be subacute and atypical diverticulitis
responsible. In one study, the risk of recurrence was four A small number of patients experience recurrent episodes
times greater in patients with a colosigmoid anastomosis of left lower quadrant abdominal pain that are not accompa-
than in those with a colorectal anastomosis.169 Reoperation nied by the classic findings of acute diverticulitis (e.g., fever
requires a dissection that commences in noninflamed tissue. and leukocytosis). The inflammatory changes associated
Dissection may be particularly difficult near the pelvic with diverticula in this subgroup have been referred to as
sidewall because of fibrosis; ureteral stenting may facilitate atypical, subacute, or smoldering diverticulitis.170–172 Surgery
identification of the ureters. has been effective in management of smouldering disease.173
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gastro diverticular disease — 16
only a chest x-ray documenting free air before they are taken
to the operating room. Given the varied complications
of diverticular disease and the numerous options for surgi-
cal treatment, it is most convenient to divide the relevant
operations into emergency procedures and elective proce-
dures. Such a division facilitates discussion of technical
issues, preoperative evaluation, and management of
complications.
As noted, in the emergency setting, a demonstration of
pneumoperitoneum may be the only workup performed. In
fact, in most patients with perforated diverticulitis, pneumo-
peritoneum is the initial presentation.176,177 In patients who
present with massive lower GI hemorrhage, angiographic
demonstration of the bleeding site is known to reduce
operative mortality, even if therapeutic superselective
embolization is unsuccessful in controlling the bleeding.178,179
The other complication of diverticular disease that may
Figure 19 Giant sigmoid diverticulum opacified during a barium necessitate an emergency operation is colonic obstruction.
enema examination.167 A careful history may reveal progressive obstructive symp-
toms, but if the patient presents with complete obstruction
and cecal dilatation, urgent decompression is required.
In this setting, retrograde administration of a water-soluble
In this setting, there is not always a direct association enema may be very helpful—at least for delineating
between endoscopic and clinical findings; endoscopic the level of the obstruction, if not the specific cause.176,180
evidence of diverticular inflammation has been seen in Communication with the radiologist should be maintained
asymptomatic patients.174 Endoscopic findings suggestive of to prevent both overly forceful instillation of the contrast
subacute or smoldering diverticulitis are a relatively rigid
material and the use of barium, which may cause problems
sigmoid colon or increased spasm along with a thickened
if the agent cannot be evacuated.
colon. It has been suggested that there is a relation between
When surgical treatment of diverticular disease is to be
diverticular disease and colitis (diverticular colitis).175 This
performed in the elective setting, a detailed preoperative
may represent a different disease entity than traditional sig-
evaluation is imperative. The key point here is that objective
moid diverticulitis.67 Patients with chronic lower abdominal
pain should undergo imaging studies and endoscopic evalu- evidence of diverticulitis must be obtained at some point in
ation, and other disorders (e.g., irritable bowel syndrome, the care of the patient. Too often, symptoms of irritable bowel
inflammatory bowel disease, drug-induced symptoms, syndrome are confused with those of diverticulitis, with the
and bowel ischemia) should be excluded. In most cases of result that the patient carries an incorrect diagnosis.181–184 In
atypical diverticulitis, endoscopic findings are normal.171 In the most common scenario, CT scanning is performed when
carefully selected patients, colectomy often eliminates the a patient is experiencing left-side pain, possibly associated
abdominal pain, and many of these patients are eventually with fever, nausea, anorexia, or abdominal distention. A
found to have histologic signs of acute and chronic mucosal finding of pericolonic inflammation in an area of diverticu-
inflammation.171 losis is the definitive radiographic presentation.185,186 Preop-
erative endoscopic evaluation of the colon, whenever
feasible, is extremely valuable not only for confirming the
Preoperative Evaluation
presence of diverticulosis but also for ruling out inflamma-
The extent of the preoperative evaluation received by tory bowel disease or even a neoplastic lesion.
patients undergoing surgical treatment of diverticular It is possible to expend a great deal of effort on trying to
disease is dictated predominantly by the urgency of the demonstrate a diverticular fistula. In many circumstances,
situation. Whereas patients with recurrent symptoms will however, this task proves difficult to accomplish. In our
undergo repeated assessments with myriad diagnostic tests view, demonstration of a diverticular fistula should not be
before the decision is made to proceed with surgical inter- considered a mandatory precondition for operative treat-
vention, patients with perforated diverticulitis may have ment. A strong history of either a colovaginal or a colovesi-
cal fistula with suggestive findings on CT scans (e.g., air in
the bladder or pericolonic inflammation contiguous with
either the bladder or the vagina) constitutes a sufficient
Table 5 Differential Diagnoses of Recurrent indication for surgical resection.187,188
Diverticulitis
Crohn disease Operative Planning
Irritable bowel syndrome
Carcinoma In planning the operative approach to a patient with
Ischemic colitis diverticular disease, the major decision is whether to perform
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100
90
80
70
60
50
40
30
20
10
0
2005 2006 2007 2008 2009 2010
Figure 20 Trends in operative techniques, Hartford Hospital 2005–2010, for scheduled procedures for diverticulitis. HALS = hand-assisted
laparoscopic surgery; LAP = pure laparoscopic procedure.
Step 5—Alternative (Primary Anastomosis with Diverting by occluding the proximal bowel and placing the anasto-
Ileostomy): Creation of Colorectal Anastomosis motic area under water while air is insufflated into the
As an alternative to a colostomy, the surgeon may elect to rectum via a rigid proctoscope.
perform a primary colorectal anastomosis with a diverting
ileostomy. The anvil of a circular stapler is positioned in the Troubleshooting It is helpful to divide the mesentery
proximal colon, and a purse-string suture is placed around where it is draped over the anvil. This measure diminishes
it. If there is any gaping of the tissue around the shaft of the the risk of bleeding from the circular staple line while also
anvil, a second suture may be added for reinforcement. providing a greater length of colon for the anastomosis.
The stapler is inserted through the anus, with the shaft If there is any question regarding possible tension on the
being brought out through either the anterior wall of the anastomosis, the splenic flexure should be fully mobilized.
rectum or the top of the rectal stump, adjacent to the staple
Step 6—Alternative (Primary Anastomosis with Diverting
line. The stapler is then engaged, with care taken to ensure
Ileostomy): Construction of Loop Ileostomy
that no extraneous tissue is caught between the body of the
stapler and the anvil and that the proximal bowel is not A loop ileostomy is created in the right lower quadrant
twisted on its mesentery. The stapler is fired to create the using a muscle-splitting incision in the rectus abdominis.
anastomosis, and the integrity of the anastomosis is tested Loop ileostomies can usually be designed to be diverting;
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gastro diverticular disease — 19
Steps 1 through 4
Steps 1, 2, 3, and 4 of on-table colonic lavage are the same
as the first four steps of the Hartmann procedure.
a b
Figure 22 Hartmann procedure. (a) The colon is divided above the level of the inflammatory mass. (b) The rectum is divided below the inflam-
matory mass; division must be through normal tissue.
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gastro diverticular disease — 20
laparoscopic resection
The patient is placed in a low lithotomy position with
minimal hip flexion. The right arm is well padded and
tucked at the side because both surgeons will be operating
from the right side of the table. Video monitors are placed
on both sides of the table. It is beneficial to place the patient
5 mm
(optional)
on a bean bag because a significant portion of the operation
5 mm will be performed with the patient in extremes of positioning.
Camera
Step 1: Placement of Trocars
12 mm The first port is placed at a periumbilical location by
means of an open Hasson approach, and a 30° laparoscope
is inserted. After pneumoperitoneum is achieved, the other
ports are placed under direct vision: 5 and 12 mm ports are
placed in the right lower quadrant, and an optional 5 mm
Figure 24 Laparoscopic sigmoid resection. Recommended port port may be placed in the midepigastrium [see Figure 24].
placement is shown. The midepigastric 5 mm port is essential for The midepigastric port facilitates mobilization of the left
mobilization of the splenic flexure. colon and is essential for mobilization of the splenic flexure.
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gastro diverticular disease — 21
Step 2: Mobilization of Sigmoid Colon to colonic mobilization only increases the steepness of the
After the abdomen has been explored, the patient is placed learning curve without affording any significant benefit.
in a steep Trendelenburg position, with the right side tilted Step 3: Division of Rectum and Sigmoid Mesentery
down. This position allows gravity to retract the small bow-
el into the upper abdomen. The sigmoid colon is mobilized An incision is made in the peritoneum along the right side
from its lateral peritoneal attachments, and the colon is of the rectosigmoid mesentery and extended inferiorly to the
thereby converted to a midline structure. Mobilization is pelvic cul-de-sac. A window is created between the upper
extended superiorly along the descending colon and inferi- rectum and its mesentery and enlarged to allow insertion of
orly to the pelvic cul-de-sac. The left ureter is then identified an endoscopic gastrointestinal anastomosis (GIA) stapler
and swept laterally away from the base of the mesentery [see [see Figure 25]. The stapler is then fired once or twice to
Video 1]. divide the rectosigmoid bowel. The mesentery of the
sigmoid colon is sequentially divided with staplers, clips,
Division of colovaginal or colovesical fistula In most an ultrasonic scalpel, or the LigaSure system (Valleylab,
patients, the fistula can be pinched off with no visible defect Boulder, CO) [see Video 2].
in either the bladder or vagina or a very small defect.
Step 4: Exteriorization of Sigmoid Colon
Management options include leaving a Foley catheter for
7 to 10 days or placing a few absorbable sutures over the Once the colon is mobilized and the blood supply is
defect and leaving a closed suction drain behind the bladder divided, either the Hasson incision is enlarged or a Pfan-
or vagina. nenstiel incision is made to exteriorize the bowel, which is
then divided proximally. The anvil of a circular stapler is
Alternative approach to colonic mobilization and divi- inserted in the proximal colon and secured with a purse-
sion In place of the conventional approach (see above), string suture. The bowel is then replaced into the abdomen,
a medial-to-lateral approach can be undertaken. In this and the incision is closed.
approach, the initial dissection proceeds from the right side
Step 5: Creation of Colorectal Anastomosis
of the colon, mobilizing the superior rectal vessels from the
sacral promontory. The left ureter is then visualized through After pneumoperitoneum is recreated, the circular stapler
the window thus created before the sigmoid mesentery is is inserted transanally. The shaft is brought out through
divided. Division of the sigmoid mesentery is performed in either the top of the rectal stump or the anterior wall of
a proximal-to-distal direction, with the inferior mesenteric the rectum [see Figure 26]; the former is preferred if bowel
vessels generally divided first. Once the sigmoid mesentery length is an issue. After the stapler is engaged but before it
has been completely divided, the bowel is transected with is fired, the proximal colon is inspected to confirm that it is
staplers at the rectosigmoid junction. not twisted. The stapler is then fired, and the anastomosis is
The advantage of the traditional approach is that sur- then tested under water to confirm the absence of an air
geons are more familiar with it from corresponding open leak. Intraoperative colonoscopy may also be performed to
procedures. In our view, given the difficulty of mastering ensure the integrity of the anastomosis. If a leak is detected,
laparoscopic colon surgery, the medial-to-lateral approach laparoscopic sutures can be placed across the anastomosis
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gastro diverticular disease — 22
Steps 1 and 2
The first two steps of a hand-assisted laparoscopic
Figure 25 Laparoscopic sigmoid resection. Division of the rectum resection are identical to steps 1 and 2 of a full laparoscopic
with the endoscopic stapler is shown. resection.
Video 2 Hand-assisted division of the superior rectum and division of the rectosigmoid mesentery.
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gastro diverticular disease — 23
Step 4: Division of Rectum and Sigmoid Mesentery and makes its closure safer by protecting the surrounding
The surgeon’s left hand is used to facilitate creation of a structures [see Figure 29]. Furthermore, the presence of the
window between the rectum and the underlying mesentery. hand in the pelvis not only assists in testing the anastomosis
An endoscopic GIA stapler is safely guided through this but also helps the surgeon better assess the degree of tension
window, and the bowel is divided [see Figure 28a]. The hand (if any) on the anastomosis. Given that the size of the hand
is then used to isolate segments of the mesentery for divi- port is similar to that of the extraction site in a full laparo-
sion [see Figure 28b], as well as to help control vessels that scopic resection, we recommend that a hand-assisted
continue to bleed despite having been divided. approach be used in difficult or complex cases.
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gastro diverticular disease — 24
a b
Figure 28 Hand-assisted laparoscopic resection. (a) Placement of the surgeon’s hand intracorporeally facilitates division of the rectum. (b) The
surgeon’s hand isolates mesenteric vessels for subsequent division.
a b
Figure 29 Hand-assisted laparoscopic resection. (a) The surgeon’s hand guides engagement of the circular stapler, protecting surrounding
pelvic structures from the stapler. (b) The anvil and stapler are engaged and the circular stapler has been fired to complete the anastomosis.
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gastro diverticular disease — 25
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gastro diverticular disease — 26
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