Clinical ReviewDiverticulitis: when and how to operate?
Introduction
Colonic diverticulosis is among the most common diseases of developed western countries. Its true prevalence is difficult to measure since most individuals are asymptomatic. However, an increase in its prevalence has been detected and demonstrated over the course of time by various clinical, radiological and epidemiological studies as well as in various autopsy series. Its pathogenesis is attributed to genetic and environmental factors among which the most striking pathogenic factor was found to be a low fibre diet [1], [2] along with some other contributing predisposing factors such as obesity, decreased physical activity, corticosteroids, NSAIDs, alcohol and caffeine intake, cigarette smoking, and polycystic kidney disease [3], [4], [5], [6] as well as some other important epidemiologic factors such as age, geography, lifestyle, and ethnicity [7] that could possibly increase the incidence of diverticular disease and related attacks and subsequent complications. The changing pattern of distribution of colonic diverticula provides important insights into the genetic and environmental factors that explain the difference in predominant site of diverticulosis among different races and geographic locations. The diverticula tend to occur almost always in the left side of the colon (50–90%), particularly the sigmoid colon [8], in Western societies, whereas right-sided predominance is mostly encountered in Asia with an incidence rate of 76% [9]. Studies so far have confirmed its predominant prevalence in industrialised nations in about 5–10% of the population by age 50, 30% of those aged over 50, in 50% of those over 70 and in 66% of people over 85 years of age [10].
While most people with diverticular disease remain asymptomatic, between 10 and 25% of patients with diverticulosis will ultimately progress to diverticulitis, and of these 15% will develop significant complications [10], [11], [12]. Diverticulitis results from inflammation and subsequent perforation of a colonic diverticulum. The actual incidence of symptomatic inflammation leading to hospitalisation is unknown, but it is estimated at 1–2% [13]. However, diverticular disease and its complications are responsible for 41% of all emergency admissions to hospitals with large bowel pathology in the USA. Ten to 20% of those who are hospitalised will eventually require an operation [14].
Those who survive an attack without surgical intervention do still have a yearly-calculated risk of 2% for subsequent attacks [10], [15], [16]. In general, 1% of all people with colonic diverticula will be operated on at some point in their lives because of a diverticulitis related complication [17].
Patients with acute diverticulitis may present with symptoms ranging from minor complaints to life-threatening clinical pictures in association with its complications. Approximately 75% of patients hospitalised for acute colonic diverticulitis respond to non-operative management that includes appropriate antibiotic therapy, bowel rest and low residue diet, and yet they have a mortality rate of approximately 1–2% [10], [18]. Operative intervention is warranted in the remaining 25% of patients because of signs and symptoms of generalised peritonitis due to diverticular disease complications such as abscess, free perforation, fistulisation or obstruction. Most large case series report an overall mortality for patients requiring operative intervention between 12 and 36% [19], [20].
Surgical treatment of acute diverticulitis has evolved over the course of approximately 100 years since drainage and proximal colostomy was described by Mayo in 1907. After introduction of the three-stage resection, it was realised that morbidity and mortality could be reduced by removing the infected segment of colon first by exteriorisation and later by resection and end colostomy, the Hartmann procedure. Up until 1980 it was generally accepted that resection and stoma were the correct surgical treatments [21]. Soon after, resection and primary anastomosis started to take its place in the treatment, however, many surgeons were still reluctant to accept and perform this concept except in mild cases either with pre-operative bowel cleansing or with intra-operative on-table lavage. However, the controversy of single-stage operation, i.e. resection and anastomosis, is still a hot topic with its current challenging position with regard to its superiority, advantages and disadvantages over other operative options in advanced peritonitis.
In order to be able to provide a more realistic approach to solve diverticulitis and its associated complications surgically and to understand and analyse the outcomes of the treatment modalities, one must consider peri-operative variables, the stage of peritonitis, operative alternatives, and outcome with each of the procedures.
Section snippets
Indications for operative treatment
Diverticular disease can be classified as symptomatic uncomplicated disease, recurrent symptomatic disease, and complicated disease [22]. This classification scheme reflects the spontaneous course of the disease and helps us understand the clinical progression from one stage to the next so that it enables us to analyse each and every stage and ultimately to determine the exact timing and indication for surgical treatment of the disease.
The indications for surgical treatment of diverticulitis
Initial evaluation and ancillary diagnostic modalities
Initial assessment of the patient with suspected diverticulitis is similar to that of any patient presenting with abdominal pain and comprises a through history and physical examination including abdominal, rectal, and pelvic examinations.
The majority of patients present with left lower quadrant pain (93–100%), fever (57–100%), and leukocytosis (69–83%) [23]. Other associated manifestations may include nausea, vomiting, constipation, diarrhoea, dysuria, and urinary frequency. One should also
Operative goals and staging systems
Whether elective, semi-elective or emergent, regardless of intervention timing, the goals of the surgical procedure are to control or prevent sepsis, eliminate further complications such as fistula or obstruction, remove the causative diseased colonic segment, and restore intestinal continuity. One should also consider minimisation of morbidity, length of hospitalisation, cost, and maximisation of survival and quality of life.
The operative treatment of acute left-sided diverticulitis must be
Treatment options and recommendations based on staging systems
For the various clinical stages of perforated diverticulitis in the complicated disease group, despite of the many classification methods available and offered in the literature, today most commonly preferred and used classification system is the original or modified Hinchey classification [38], [41]. Surgical treatment options with the contribution of the auxiliary methods like CT guided drainage and on-table lavage to downstage the type and complexity of the surgical operations, may be based
Principles of operation and operative techniques
There are principles and operative techniques to follow in terms of application of pre-planned, less invasive surgery that decreases the chances of staged operations and thus providing the possibility of achieving good operative outcome that improves quality of life along with a decrease in the rate of complications as well as in morbidity and mortality of the patient.
General principles that are recommended in association with the timing of the operation are given below.
In elective cases,
Special circumstances
There are special circumstances where the general recommendations in the diagnostic workup and treatment of diverticulitis may not apply. This is closely associated with the presence of the factors such as presentation of the disease, the patient’s response to the disease and to the therapy for the disease.
Conclusion
Although colonic diverticulitis is a benign condition, it can sometimes be very challenging to diagnose and treat. It is a common disease and needs to be taken into consideration in the differential diagnosis of patients with abdominal complaints. The increase in morbidity and mortality is associated with the stage of peritonitis and patient related co-morbidities. Therefore, it is worthwhile to emphasise that staging is not only the crucial key for accurate diagnosis and treatment but it also
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