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==Overview== | ==Overview== | ||
Surgery is not the first | Surgery is not the first line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with [[peritonitis]], who are unresponsive to treatment, who have [[intestinal obstruction]], or with [[abscess]] formation. Elective surgery may be performed and it depends on many factors like the age of the patient, the severity score, and persistence of symptoms. | ||
==Surgery== | ==Surgery== | ||
Surgical intervention in patients with diverticulitis is not the first line of treatment unlike the medical therapy | Surgical intervention in patients with diverticulitis is not the first line of treatment, unlike the medical therapy. However, surgery is required in complicated patients with diverticulitis who are unresponsive to medical therapy and 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]] | ||
| Line 14: | Line 14: | ||
=== Emergency or urgent surgery === | === Emergency or urgent surgery === | ||
Emergency [[surgery]] is performed in life threatening cases of diverticulitis when it is complicated by [[perforation]]. Urgent surgery | Emergency [[surgery]] is performed in life threatening cases of diverticulitis when it is complicated by [[perforation]]. Urgent surgery is an operation that is required to be done immediately.<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref><ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref> | ||
*Indications of the urgent surgery: | *Indications of the urgent surgery: | ||
**Diverticulitis complicated by [[peritonitis]] | **Diverticulitis complicated by [[peritonitis]] | ||
| Line 23: | Line 23: | ||
*Surgery procedures and techniques:<ref name="pmid16741596">{{cite journal| author=Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons| title=Practice parameters for sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 7 | pages= 939-44 | pmid=16741596 | doi=10.1007/s10350-006-0578-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16741596 }} </ref> | *Surgery procedures and techniques:<ref name="pmid16741596">{{cite journal| author=Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons| title=Practice parameters for sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 7 | pages= 939-44 | pmid=16741596 | doi=10.1007/s10350-006-0578-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16741596 }} </ref> | ||
**Based on the status of the patient and the severity of the disease (according to Hinchey classification of severity), the patient undergoes an emergent [[sigmoid]] [[resection]] with or without [[anastomosis]]. | **Based on the status of the patient and the severity of the disease (according to Hinchey classification of severity), the patient undergoes an emergent [[sigmoid]] [[resection]] with or without [[anastomosis]]. | ||
**The most common procedure | **The most common procedure in these cases is the Hartmann procedure. | ||
**Hartmann technique includes sigmoid [[colectomy]], end sigmoid or descending [[colostomy]], and closure of the [[rectal]] stump. These colostomies may not be closed. | **The 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. The anastomosis may have a | **Besides the Hartmann technique, [[resection]] and [[anastomosis]] with [[ileostomy]] can be performed. The [[anastomosis]] may have a lower mortality rate than operations without [[anastomosis]].<ref name="pmid12780890">{{cite journal| author=Zorcolo L, Covotta L, Carlomagno N, Bartolo DC| title=Safety of primary anastomosis in emergency colo-rectal surgery. | journal=Colorectal Dis | year= 2003 | volume= 5 | issue= 3 | pages= 262-9 | pmid=12780890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12780890 }} </ref><ref name="pmid15622591">{{cite journal| author=Salem L, Flum DR| title=Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. | journal=Dis Colon Rectum | year= 2004 | volume= 47 | issue= 11 | pages= 1953-64 | pmid=15622591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15622591 }} </ref><ref name="pmid8495323">{{cite journal| author=Kronborg O| title=Treatment of perforated sigmoid diverticulitis: a prospective randomized trial. | journal=Br J Surg | year= 1993 | volume= 80 | issue= 4 | pages= 505-7 | pmid=8495323 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8495323 }} </ref> | ||
A video shows how Hartmann procedure is performed: | A video shows how Hartmann procedure is performed: | ||
| Line 31: | Line 31: | ||
===Elective surgery=== | ===Elective surgery=== | ||
Unlike the emergent surgery, elective surgery can be performed after proper responsive treatment. The surgeon decides whether the patient requires | Unlike the emergent surgery, elective surgery can be performed after proper responsive treatment. The surgeon decides whether the patient requires [[colon]] [[resection]] or not. Elective surgery depends on many factors like the age of the patient, the severity score, and persistence of symptoms. Based on many studies, around one-third of the patients will have symptoms of the disease again after the first episode. Elective surgery may be indicated in some cases, but it is indicated on a case-by-case basis.<ref name="pmid15685694">{{cite journal| author=Janes S, Meagher A, Frizelle FA| title=Elective surgery after acute diverticulitis. | journal=Br J Surg | year= 2005 | volume= 92 | issue= 2 | pages= 133-42 | pmid=15685694 | doi=10.1002/bjs.4873 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15685694 }} </ref> | ||
*Cases that may require elective surgery:<ref name="pmid25654646">{{cite journal| author=Rose J, Parina RP, Faiz O, Chang DC, Talamini MA| title=Long-term Outcomes After Initial Presentation of Diverticulitis. | journal=Ann Surg | year= 2015 | volume= 262 | issue= 6 | pages= 1046-53 | pmid=25654646 | doi=10.1097/SLA.0000000000001114 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25654646 }} </ref><ref name="pmid26855395">{{cite journal| author=Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM| title=Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications. | journal=Dis Colon Rectum | year= 2016 | volume= 59 | issue= 3 | pages= 208-15 | pmid=26855395 | doi=10.1097/DCR.0000000000000533 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26855395 }} </ref> | *Cases that may require elective surgery:<ref name="pmid25654646">{{cite journal| author=Rose J, Parina RP, Faiz O, Chang DC, Talamini MA| title=Long-term Outcomes After Initial Presentation of Diverticulitis. | journal=Ann Surg | year= 2015 | volume= 262 | issue= 6 | pages= 1046-53 | pmid=25654646 | doi=10.1097/SLA.0000000000001114 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25654646 }} </ref><ref name="pmid26855395">{{cite journal| author=Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM| title=Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications. | journal=Dis Colon Rectum | year= 2016 | volume= 59 | issue= 3 | pages= 208-15 | pmid=26855395 | doi=10.1097/DCR.0000000000000533 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26855395 }} </ref> | ||
**Diverticulitis complicated by [[fistula]]. | **Diverticulitis complicated by [[fistula]]. | ||
**High-risk diverticulitis patients like [[immunocompromised]] patients. | **High-risk diverticulitis patients like [[immunocompromised]] patients. | ||
**Patients with past history of diverticulitis but recovered. | **Patients with past history of diverticulitis but who recovered. | ||
**Chronic diverticulitis patients who develop recurrent symptoms of the [[disease]]. | **[[Chronic]] diverticulitis patients who develop recurrent symptoms of the [[disease]]. | ||
* | *Surgical procedures and techniques: | ||
** | **Patients with [[abscess]], should undergo [[CT]]-guided [[percutaneous]] drainage of the [[abscess]]. The procedure depends on the severity score of the [[disease]] and the size of the [[abscess]]. [[Abscess]] that is smaller than 3 cm and not associated with [[peritonitis]] can be treated conservatively with [[antibiotics]]. Large [[abscesses]] larger than 4 cm should be treated with [[percutaneous]] drainage.<ref name="pmid16498095">{{cite journal| author=Siewert B, Tye G, Kruskal J, Sosna J, Opelka F, Raptopoulos V et al.| title=Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. | journal=AJR Am J Roentgenol | year= 2006 | volume= 186 | issue= 3 | pages= 680-6 | pmid=16498095 | doi=10.2214/AJR.04.1708 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16498095 }} </ref> | ||
**After performing the percutaneous drainage, elective [[colectomy]] should be done | **After performing the percutaneous drainage, elective [[colectomy]] should be done to prevent recurrence of the symptoms.<ref name="pmid15784040">{{cite journal| author=Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C et al.| title=The management of complicated diverticulitis and the role of computed tomography. | journal=Am J Gastroenterol | year= 2005 | volume= 100 | issue= 4 | pages= 910-7 | pmid=15784040 | doi=10.1111/j.1572-0241.2005.41154.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15784040 }} </ref> | ||
**[[Colectomy]] starts in the proximal [[bowel]] extending to the upper [[rectum]]. | **[[Colectomy]] starts in the proximal [[bowel]] extending to the upper [[rectum]]. | ||
**In some cases, laparoscopic [[colectomy]] is preferred as it is less painful, | **In some cases, laparoscopic [[colectomy]] is preferred as it is less painful, creates a smaller scar, and fewer complications occur.<ref name="pmid14609864">{{cite journal| author=Guller U, Jain N, Hervey S, Purves H, Pietrobon R| title=Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases. | journal=Arch Surg | year= 2003 | volume= 138 | issue= 11 | pages= 1179-86 | pmid=14609864 | doi=10.1001/archsurg.138.11.1179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14609864 }} </ref><ref name="pmid11116412">{{cite journal| author=Tuech JJ, Pessaux P, Rouge C, Regenet N, Bergamaschi R, Arnaud JP| title=Laparoscopic vs open colectomy for sigmoid diverticulitis: a prospective comparative study in the elderly. | journal=Surg Endosc | year= 2000 | volume= 14 | issue= 11 | pages= 1031-3 | pmid=11116412 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11116412 }} </ref> | ||
Video explaining the CT guided percutaneous abscess drainage: | Video explaining the CT guided percutaneous abscess drainage: | ||
Revision as of 20:29, 4 August 2017
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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
Surgery is not the first line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with peritonitis, who are unresponsive to treatment, who have intestinal obstruction, or with abscess formation. Elective surgery may be performed and it depends on many factors like the age of the patient, the severity score, and persistence of symptoms.
Surgery
Surgical intervention in patients with diverticulitis is not the first line of treatment, unlike the medical therapy. However, surgery is required in complicated patients with diverticulitis who are unresponsive to medical therapy and 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 is an operation that is required to be done immediately.[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 percutaneous 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), the patient undergoes an emergent sigmoid resection with or without anastomosis.
- The most common procedure in these cases is the Hartmann procedure.
- The Hartmann technique includes sigmoid colectomy, end sigmoid or descending colostomy, and closure of the rectal stump. These colostomies may not be closed.
- Besides the Hartmann technique, resection and anastomosis with ileostomy can be performed. The anastomosis may have a lower mortality rate than operations without 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 colon resection or not. Elective surgery depends on many factors like the age of the patient, the severity score, and persistence of symptoms. Based on many studies, around one-third of the patients will have symptoms of the disease again after the first episode. Elective surgery may be indicated in some cases, but it is indicated on a case-by-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 who recovered.
- Chronic diverticulitis patients who develop recurrent symptoms of the disease.
- Surgical procedures and techniques:
- Patients with abscess, should undergo CT-guided percutaneous drainage of the abscess. The procedure depends on the severity score of the disease and the size of the abscess. Abscess that is smaller than 3 cm and not associated with peritonitis can be treated conservatively with antibiotics. Large abscesses larger than 4 cm should be treated with percutaneous drainage.[11]
- After performing the percutaneous drainage, elective colectomy should be done 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, creates a smaller scar, and fewer complications occur.[13][14]
Video explaining the CT guided percutaneous abscess drainage: {{#ev:youtube|v=WQv26x3bnws|}}
Video showing laparoscopic 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.