Diverticulitis surgery: Difference between revisions
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==Surgery== | ==Surgery== | ||
Surgical intervention in patients with diverticulitis is not the first line of treatment unlike the medical therapy in such patients. However, surgery is required in the complicated patients with diverticulitis who are unresponsive to the medical therapy and the conservative measures against the disease.<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> Hence, surgical intervention is the mainstay of therapy for complicated acute diverticulitis. Complicated cases are often associated with: | Surgical intervention in patients with diverticulitis is not the first line of treatment unlike the medical therapy in such patients. However, surgery is required in the complicated patients with diverticulitis who are unresponsive to the medical therapy and the conservative measures against the disease.<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> Hence, surgical intervention is the mainstay of therapy for complicated acute diverticulitis. Complicated cases are often associated with: | ||
Peritonitis | *[[Peritonitis]] | ||
Failed percutaneous drainage of an abscess | *Failed percutaneous drainage of an [[abscess]] | ||
Enterocutaneous fistula formation | *Enterocutaneous [[fistula]] formation | ||
Bowel obstruction | *[[Bowel obstruction]] | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]Ahmed Elsaiey, MBBCH [3]
Overview
If symptoms of diverticulitis are frequent, or the patient does not respond to antibiotics and resting the colon, the doctor may advise surgery. The surgeon removes the affected part of the colon and joins the remaining sections. This type of surgery—called colon resection—aims to prevent complications and future diverticulitis. The doctor may also recommend surgery for complications such as a fistula or partial intestinal obstruction.
Immediate surgery may be necessary when the patient has other complications, such as perforation, a large abscess, peritonitis, complete intestinal obstruction, or severe bleeding. In these cases, two surgeries may be needed because it is not safe to rejoin the colon right away. During the first surgery, the surgeon cleans the infected abdominal cavity, removes the portion of the affected colon, and performs a temporary colostomy, creating an opening, or stoma, in the abdomen. The end of the colon is connected to the opening to allow normal eating while healing occurs. Stool is collected in a pouch attached to the stoma. In the second surgery several months later, the surgeon rejoins the ends of the colon and closes the stoma.
Surgery
Surgical intervention in patients with diverticulitis is not the first line of treatment unlike the medical therapy in such patients. However, surgery is required in the complicated patients with diverticulitis who are unresponsive to the medical therapy and the conservative measures against the disease.[1] Hence, surgical intervention is the mainstay of therapy for complicated acute diverticulitis. Complicated cases are often associated with:
- Peritonitis
- Failed percutaneous drainage of an abscess
- Enterocutaneous fistula formation
- Bowel obstruction
Emergency or urgent surgery
Emergency surgery is performed in life threatening cases of diverticulitis when it is complicated by perforation. Urgent surgery means operation that required to be done immediately in the same hospitalizaiton of the patient.[2][3]
- Indications of the urgent surgery:
- Diverticulitis complicated by peritonitis
- Patient becomes unresponsive to the medical treatment
- Diverticulitis complicated by intestinal obstruction
- Abscess formation and not responsive to the percutanous drainage
- Enterocutaneous fistula formation
- Surgery procedures and techniques:[4]
- Based on the status of the patient and the severity of the disease (according to Hinchey classification of severity), patient undergoes an emergent sigmoid resection with or without anastomosis.
- The most common procedure of operation to be done in these cases is called Hartmann procedure.
- Hartmann technique includes sigmoid colectomy, end sigmoid or descending colostomy, and closure of the rectal stump. These colostomies may not be closed.
- Besides Hartmann technique, resection and anastomosis with ileostomy can be performed. Anastomosis may have a low mortality rate than the operations with no anastomosis.[5][6][7]
A video shows how Hartmann procedure is performed: {{#ev:youtube|v=rVgBZwY4Pt8&t=175s|}}
Elective surgery
Unlike the emergent surgery, elective surgery can be performed after proper responsive treatment. The surgeon decides whether the patient requires to proceed into colon resection or not. It depends on many factors like the age of the patient, the severity score and if there are any persistent symptoms or not. Based on many studies, it was found that around third of the patients will have symptoms of the disease again after the first episode of it and from this point elective surgery may be indicated in some cases and whatsoever, it is indicated on a case to case basis.[8]
- Cases that may require elective surgery:[9][10]
- Diverticulitis complicated by fistula
- High risk diverticulitis patients like immunocompromised patients
- Patients with past history of diverticulitis but recovered
- Chronic diverticulitis patients who develop recurrent symptoms of the disease
- Surgery procedures and techniques:
- For the patients with abscess they should undergo CT guided percutaneous drainage of the abscess. It depends on the severity score of the disease and the size of the abscess. The abscess which is smaller than 3 cm and not associated with peritonitis can be treated conservatively by antibiotics. Large abscesses, more than 4 cm, should be treated by the percutaneous drainage.[11]
- After performing the percutaneous drainage, elective colectomy should be done in order to prevent recurrence of the symptoms.[12]
- Colectomy starts in the proximal bowel extending to the upper rectum.
- In some cases, laparoscopic colectomy is preferred as it is less painful, cause smaller scar and less complications to occur.[13][14]
Video explaining the CT guided percutaneous abscess drainage: {{#ev:youtube|v=WQv26x3bnws|}}
Video showing laparscopic colectomy: {{#ev:youtube|v=No4SzEmiPaM|}}
References
- ↑ Jacobs DO (2007). "Clinical practice. Diverticulitis". N Engl J Med. 357 (20): 2057–66. doi:10.1056/NEJMcp073228. PMID 18003962.
- ↑ Sheth AA, Longo W, Floch MH (2008). "Diverticular disease and diverticulitis". Am J Gastroenterol. 103 (6): 1550–6. doi:10.1111/j.1572-0241.2008.01879.x. PMID 18479497.
- ↑ Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J (1997). "Surgical management of complicated colonic diverticulitis". Br J Surg. 84 (3): 380–3. PMID 9117315.
- ↑ Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
- ↑ Zorcolo L, Covotta L, Carlomagno N, Bartolo DC (2003). "Safety of primary anastomosis in emergency colo-rectal surgery". Colorectal Dis. 5 (3): 262–9. PMID 12780890.
- ↑ Salem L, Flum DR (2004). "Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review". Dis Colon Rectum. 47 (11): 1953–64. PMID 15622591.
- ↑ Kronborg O (1993). "Treatment of perforated sigmoid diverticulitis: a prospective randomized trial". Br J Surg. 80 (4): 505–7. PMID 8495323.
- ↑ Janes S, Meagher A, Frizelle FA (2005). "Elective surgery after acute diverticulitis". Br J Surg. 92 (2): 133–42. doi:10.1002/bjs.4873. PMID 15685694.
- ↑ Rose J, Parina RP, Faiz O, Chang DC, Talamini MA (2015). "Long-term Outcomes After Initial Presentation of Diverticulitis". Ann Surg. 262 (6): 1046–53. doi:10.1097/SLA.0000000000001114. PMID 25654646.
- ↑ Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM (2016). "Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications". Dis Colon Rectum. 59 (3): 208–15. doi:10.1097/DCR.0000000000000533. PMID 26855395.
- ↑ Siewert B, Tye G, Kruskal J, Sosna J, Opelka F, Raptopoulos V; et al. (2006). "Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters". AJR Am J Roentgenol. 186 (3): 680–6. doi:10.2214/AJR.04.1708. PMID 16498095.
- ↑ Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C; et al. (2005). "The management of complicated diverticulitis and the role of computed tomography". Am J Gastroenterol. 100 (4): 910–7. doi:10.1111/j.1572-0241.2005.41154.x. PMID 15784040.
- ↑ Guller U, Jain N, Hervey S, Purves H, Pietrobon R (2003). "Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases". Arch Surg. 138 (11): 1179–86. doi:10.1001/archsurg.138.11.1179. PMID 14609864.
- ↑ Tuech JJ, Pessaux P, Rouge C, Regenet N, Bergamaschi R, Arnaud JP (2000). "Laparoscopic vs open colectomy for sigmoid diverticulitis: a prospective comparative study in the elderly". Surg Endosc. 14 (11): 1031–3. PMID 11116412.