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Emergency Surgery in Diverticulitis of the Colon
Emergency Surgery in Diverticulitis of the Colon SAMUEL F. MARSHALL, M.D., F.A.C.S.* WILLIAM C. YOUNG, M.D., F.A.C.S. **
Diverticulosis of the colon is a pathologic condition which consists of numerous diverticula in the wall of the colon. These diverticula may be scattered throughout the entire length of the colon but are found most frequently in the sigmoid colon. When they become inflamed, the process is termed diverticulitis. Complications of diverticulitis are common and often their treatment is urgent; immediate surgical intervention is often necessary to avoid serious sequelae and even death. Diverticula are small pouches that arise in the wall of the colon; the thin pouch wall is made up of mucosa covered with peritoneum. The small hernial sacs occur along arteries which penetrate the peritoneum to the mucosa, and are commonly found at the antimesenteric surface of the colon between the taenial bands where the colon is deficient in longitudinal muscle.
INCIDENCE
The incidence of diverticulosis is fairly high. Its incidence in patients who have radiologic examinations for gastrointestinal disease is reported to be 15 to 20 per cent. Ransom ll stated that in approximately 15,000 x-ray examinations, diverticula were noted in one of every eight patients. Thompsonll reported that 500 deaths in England and Wales each year are caused by diverticulitis of the colon. Bllrborka2 reported that diverticulitis was uncommon in patients under the age of 40 but that 5 to 20 per cent of patients more than 40 years of age had diverticula and diverticulitis developed in 15 to 20 per cent of this group. The colonic segment most involved in diverticulosis is the sigmoid and
* Staff, New England Baptist and New England Deaconess Hospitals, Boston, Massachusetts
** Associate Surgeon, New England Baptist Hospital.
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descending colon. Judd and Waugh 6 stated that diverticulitis was present only in the sigmoid in 98 per cent of cases. Mailor 8 in a necropsy study reported that diverticula occurred in the sigmoid in 40 per cent of cases and in the entire colon in 30 per cent. In a group of 294 cases studied by Boles3 the diverticula were in the cecum in 2 per cent and in the sigmoid and descending colon in 55 per cent. The entire colon was involved in 33 per cent. Sex seems to have little influence on frequency and occurrence of this disease. The sex incidence was about equal in Boles' series-134 men and 160 women. However, most authorities quote a slightly higher incidence in men.
THERAPEUTIC INDICATIONS In patients who have uncomplicated diverticulosis, severe symptoms do not develop nor does the condition endanger life. The complications of diverticulitis, however, account for severe abdominal distress and serious illness, and may be associated with a high mortality. The complications of diverticulosis and diverticulitis can often be prevented by instituting a careful dietary and medical regimen early in those patients with diverticulosis; in 80 per cent the diverticulosis can be managed medically and only a small percentage will ultimately require operation. Surgical treatment can be utilized with a great margin of safety if the operation is not postponed until more serious complications-even sequelae that may cause deatharise. Leis 7 stated that diverticulitis develops in 10 to 20 per cent of persons with diverticulosis, and will require operation. In Boles' study of 294 patients with diverticulosis, diverticulitis developed in 73 but only 16 required surgical intervention. In a more recent consecutive series of patients whom we 9 have operated on, 7 of 20 patients who had resections for diverticulitis required immediate operation for complications such as abscess, perforation or subacute obstruction of the colon. Many patients have had previous attacks of acute diverticulitis that subsided under conservative management. One attack of inflammation does not forecast future attacks, but without good medical care, diverticulitis tends to recur and more extensive alterations of the colon are found, with a higher incidence of serious complications, most frequently in the form of an inflammatory tumor mass or stricture of the colon with obstru ction. Repeated attacks of diverticulitis usually result in complications that require operation. In our experience, complications of diverticulitis, such as obstruction, perforation and bleeding, occurred in 22.5 per cent of patients who had only one attack, whereas these complications were found in 57.5 per cent of patients who had had more than one attack. Diverticular disease of the colon, either diverticulosis or diverticulitis, occurs frequently, with about 5 to 7 per cent of patients requiring operative treatment for relief of symptoms. All too often in the past, surgical treatment was used only for patients with serious complications, and multiple-stage operations were
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employed in most instances. Today, elective surgery, consisting of one-stage colon resection, can be done during an inactive phase of the inflammatory process with almost no operative mortality. However, in a small percentage of cases the existence of diverticular disease is not suspected until a serious complication develops that may result in fatality. Baconl strongly advocated prophylactic resection as definitive therapy for diverticulitis in an effort to avoid emergency operation for the serious complications that may carry a high operative mortality. In his experience with 326 patients, 11.3 per cent required emergency procedures, with a mortality of 8.1 per cent. In our own experience 9 during a six-year period (January 1954 to January 1960) of 180 resections performed for diverticulitis, none was an emergency procedure. The last consecutive 118 patients (65.5 per cent of the entire series) had one-stage resections with no operative deaths. In an effort to prevent the more serious complications and in view of the high incidence of diverticular disease after the age of 40, every patient more than 40 years of age should have a barium enema examination to disclose the presence of diverticular disease and to alert the physician to the possibility that diverticulitis may be the cause of an acute abdominal catastrophe. Previous x-ray studies are a valuable record and help immeasurably in the accurate determination of the etiology of an acute abdominal condition.
COMPLICATIONS OF DIVERTICULOSIS AND DIVERTICULITIS
Complications of diverticulosis that often demand emergency operations are perforation of a diverticulum, localized abscess, a spreading or generalized peritonitis, massive bleeding, colon or small bowel obstruction, and portal pyemia or liver abscess. Acute obstruction of the small intestine may occur but distinction must be made between paralytic ileus and a true obstruction. Paralytic ileus frequently occurs with spreading peritonitis. Other complications rarely demand immediate surgical intervention-acute diverticulitis, rarely acute colonic obstruction or acute colovesical fistula. Occasionally acute obstruction of the colon will result from carcinoma and at times in the differential diagnosis it may be difficult to determine whether acute diverticulitis or carcinoma is the cause of the obstruction. Muir'slo experience and opinion are well worth citing: "The clinical course is usually longer in diverticulitis. Patients with diverticulitis are usually obese but with carcinoma there is often a history of weight loss. Pain is more common in diverticulitis and is recurrent. Alteration of bowel habit is more characteristic of carcinoma. Elevated temperature and leukocytosis are more apt to be present with diverticulitis. Rectal bleeding recurs in 20 per cent of diverticulitis but is persistent with carcinoma and rarely massive in the latter. Palpable tumor may occur with both diseases but is more apt to be tender in diverticulitis."
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Figure 1 (Case I). Man aged 84 years. Obstruction of sigmoid due to diverticulitis with repeated attacks. Numerous diverticula throughout sigmoid colon with marked narrowing of sigmoid.
Concomitant Tumor Carcinoma occasionally coexists with diverticulitis but there is no evidence that carcinoma develops because of inflammation of the colon from diverticulitis. CASE I. An 84 year old physician, known to have diverticulosis which had been treated medically for years, was admitted because of increasing pain in the left lower quadrant and decrease in the size of his stools, with 2 episodes of obstruction of the large intestine. A barium enema study (Fig. 1) revealed numerous diverticula throughout the sigmoid colon and to a lesser extent involving the descending colon. The roentgenogram also showed marked narrowing of the sigmoid colon. After careful preparation of the bowel, a primary resection of the sigmoid colon was performed. In addition to the diverticulosis and acute diverticulitis with marked narrowing of the sigmoid colon, a polypoid carcinoma was found which measured 3 by 2 by 1.5 em., and was suspended by a 2 by 2 cm. stalk. Pathologic evidence of metastasis was not present. The postoperative course was without incident. The stools returned to normal size, and he has been asymptomatic for 3 years.
This is a good illustration of diverticulitis with a concomitant carcinoma. Carcinoma may be difficult to demonstrate by both proctoscopy and barium enema study, and in this case it was not demonstrated on the roentgenogram.
Perforation with Small Bowel Obstruction In all complications of suspected diverticular disease a roentgenogram of the abdomen should be made in every case and may need to be repeated each day if operation is postponed. X-ray examination of the abdomen has
!I
II i
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helped us considerably to recognize the development of small bowel obstruction from adherence and kinking of the bowel at the point of diverticular leakage. CASE II. A 52 year old obese man, known to have diverticulosis, was hospitalized because of sudden onset of pain in the lower part of the abdomen 20 hours before admission. The abdomen was distended and tenderness was elicited across
Figure 2 (Case II). Man aged 52 years. A, Acute perforation (24 hours) with development of acute small bowel obstruction. X-ray of abdomen showed dilated loops of small intestine which on lateral decubitus show air-fluid levels. B, X-ray 24 hours later with oral Gastrografin. Obstruction of small intestine overlying 5th lumbar vertebra with evidence of extrinsic pressure at the point.
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the lower part of the abdomen, especially in the left lower quadrant. He was nauseated but vomiting had not occurred. The temperature was 101.4° F., the hemoglobin 15.8 gm., and the white blood cell count 18,000. A roentgenogram of the abdomen showed distention of the small bowel and multiple fluid levels in the upright position. Roentgenograms of the abdomen on 2 successive days, using Gastrografin, showed evidence of increasing partial obstruction of the small intestine overlying the fifth lumbar vertebra (Fig. 2). There was extrinsic pressure on the inferior aspect of the small intestine at this point, suggesting an inflammatory mass. Operation revealed a perforated diverticulum of the sigmoid colon just to the right of the midline and posterior to the urinary bladder. The perforation was localized to this area, and the terminal ileum was obstructed by its adherence to the area of perforation. This obstruction was located approximately 18 inches (45 cm.) proximal to the ileocecal valve. A surrounding localized abscess was found which contained several milliliters of thin, watery, purulent fluid. Lysis of the intimate attachment of the small bowel to the perforated diverticulum released the small intestinal obstruction. The pelvic abscess was drained.
This case is an example of small bowel obstruction occurring as a result of an acute perforation of a diverticulum of the sigmoid colon. Sigmoidoscopic examination may be helpful in a few cases in ruling out perforated carcinoma of the colon, but the diverticular opening in the bowel is rarely visualized. The sigmoidoscope usually encounters obstruction 12 to 15 cm. from the anal margin, and further insert.ion may be very painful because of adherence and angulation of the inflammatory mass of bowel. Most carcinomas, however, can be visualized with proctoscopy, permitting the physician to obtain tissue for biopsy. The rectosigmoid can be outlined with Gastrografin given by enema, but such an examination should be performed cautiously because of the possibility that the diverticulum is perforated. This examination has helped occasionally when the differential diagnosis is difficult.
Perforation with Abscess Formation Perforation of the colon is the more common complication in diverticulitis and demands surgical intervention. The diagnosis should be suspected in an obese individual with known diverticulosis. The perforation may be free, with a rapidly spreading peritonitis, but more often there is slow leakage with localized peritoneal inflammation. The adjacent viscera and omentum may seal off the area of slow leakage, with formation of an abscess. Very often the patient is not referred to the surgeon at once and a few days may elapse so that a local abscess is present when the surgeon is consulted. CASE III. A 62 year old man was hospitalized because of pain and localized tenderness in the left lower quadrant occurring one week before admission. An abscess was incised and drained, and a large amount of purulent drainage was obtained. Because of the adherence of loops of bowel and no evidence of obstruction, colostomy was not attempted. A fecal fistula resulted, as anticipated, but obstruction did not develop. A subsequent barium enema study showed diverticulitis of the sigmoid colon with perforation (Fig. 3).
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Figure 3 (Case III). Man aged 62 years. Perforated diverticulum with abscess. X-ray shows many diverticula with sinus tract at site of perforation. Abscess drained with resection of sigmoid at later date.
Three months later the patient was readmitted for elective resection. A persistent fecal fistula was present. The fistula was excised, and an anterior resection of the sigmoid colon was performed, with end-to-end anastomosis.
This case illustrates diverticulitis of the sigmoid colon with perforation and formation of an abscess which was drained, with resulting fecal fistula. An anterior resection of the perforation of the sigmoid and fecal fistula was performed at a later date after the acute process had subsided. Left-sided localization suggests strongly the diagnosis of perforated diverticula. The extreme cellulitis resulting from the perforation may cause further perforation into the bladder or adjacent viscera. X-ray visualization of air collections is not usual unless free perforation is present, and with a rapidly spreading peritonitis the presence of free air in the abdomen is more suggestive of perforated ulcer. Perforation of a solitary diverticulum on the right side may simulate acute appendicitis. CASE IV. A 69 year old woman was admitted in January, 1965 because of pain in the right lower quadrant which became progressively more severe and was associated with nausea and vomiting. A large mass was palpated in the right lower quadrant. Barium enema study showed multiple diverticula present throughout the entire colon (Fig. 4). The cecum appeared spastic and did not fill well. At operation a perforation of the cecum was found, with gangrene of the cecum and
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Figure 4 (Case IV). Woman aged 69 years. A, X-ray of colon shows multiple diverticula present throughout colon. B, Perforation of diverticulum of cecum. Inflammatory mass involving cecum. Cecum spastic and did not fill well with barium. Resection January, 1965. C, June, 1965. Perforated diverticulitis of sigmoid colon with fistula into small intestine in left lower quadrant. Operation consisted of closure of opening into small intestine and resection of sigmoid. December, 1965, patient well.
a large, unusual type of fecalith measuring 3.5 by 3 by 1.5 cm., which lined a large tract entering a closed cystic cavity. The terminal ileum was involved in this mass. In addition, diverticulitis of the sigmoid colon was noted with marked thickening of the sigmoid and an associated diverticular mass. Inasmuch as x-ray evidence of sigmoid obstruction was not present, it was thought unwise to perform a multiple procedure. In March, 1965, some 3 months after operation, the patient was readmitted because of severe pain and tenderness in the left lower quadrant. A diagnosis was made of perforation of the sigmoid colon. At operation, a walled-off perforation of a diverticulum of the midsigmoid was found, with marked reduction in the size of the lumen. A primary anterior resection was carried out. After operation, an intra-abdominal abscess developed, which was drained, and a fistula of the abdominal wall developed. Roentgenograms showed a fistulous communication between the distal jejunum and the sigmoid colon at the anastomotic site. Her general condition improved, and the small bowel drainage decreased somewhat. Arrangements were made for readmission at a later date if the fistula did not close spontaneously, and the patient was discharged. The patient was readmitted in June, 1965 because of severe pain in the left lower quadrant, and was prepared for excision of the persistent fistulous tract. It should be noted that during the past 272 months she continued to have pain in the
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left lower quadrant. At operation, diverticulitis and fistulas of the small bowel were found. The sigmoid colon was again resected and the fistulas were simply closed. Following this procedure she did extremely well. There was no evidence of wound infection, and upon discharge from the hospital she was having normal bowel movements. This case is an example of multiple diverticula with perforation of both the right and left colon. Solitary cecal diverticula are usually congenital and have considerable tendency toward inflammation and perforation. Multiple diverticula, however, occur in the cecum and ascending colon; in Boles' experience 2 per cent were located in the cecum. Perforation of diverticula, with a long pelvic sigmoid lying on the right side, may suggest acute appendicitis. The differential diagnosis of a gangrenous appendix and a perforated diverticulum of the pelvic colon may not be easy and may be established accurately only by laparotomy. We have recently had a patient with an abscess in the right side of the pelvis resulting from perforation of a diverticulum of the sigmoid colon, but the diagnosis was apparent because this patient had had an appendectomy previously. Because of the difficulty in diagnosis in right-sided inflammation, the need for immediate surgical intervention is apparent. Perforation with Spreading Peritonitis
Operation is urgently needed in instances of spreading peritonitis with perforation of a diverticulum. If the patient is seen at the onset of perforation, we believe operation is imperative, but if he is seen 8 to 12 hours after perforation, and peritonitis is localized, with abscess formation, surgery can best be deferred and the abscess drained safely at a later date. If localization does not occur, a generalized peritonitis and paralytic ileus will develop. Surgery should consist of proximal colostomy and drainage of the area of perforation. Usually, any attempt to suture the perforation is futile because of induration and edema, and suture of the fatty epiploica over the perforation is impossible since sutures will not hold in such a cellulitis. Fecal fistulas develop in most cases but, when a proximal colostomy has been established, resection can be carried out readily at a later date without undue operative risk. If the peritonitis has localized and operation is deferred, a resultant abscess can be drained safely at a more favorable time. With the development of general peritonitis from free perforation of diverticulitis, occasionally a subhepatic, subphrenic or liver abscess will be encountered. The occurrence of such abscesses should always be considered if a septic course continues, and if an abscess is found, it should be drained. The exercise of surgical judgment is difficult in all cases of perforated diverticulitis of the colon. In acute cases of colovesical fistulas, proximal colostomy is necessary. This can be done through a left muscle-splitting incision, using the descending colon for colostomy. Later, after careful preparation of the colon, the vesical fistula can be closed and the colonic stoma excised through the same incision, thus permitting a one stage resec-
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tion of the colon without increased operative risk. We prefer this method of establishing a proximal colostomy since an additional operative stage for closure of the colostomy can be avoided. If the descending colon cannot be mobilized enough to permit formation of a divided colostomy, the colostomy may be made in the transverse colon even if it is necessary to extend the left rectus incision to form the colostomy. After perforation, a definitive operation can usually be performed within three months. Simple closure of a colostomy without resection of the colon is to be condemned, since it will result in recurrence of diverticulitis in more than 80 per cent of cases. Intestinal obstruction resulting from diverticulitis is usually subacute or chronic and there is a history of repeated attacks of diverticulitis. Occasionally, however, complete obstruction does occur. In such cases, the obstruction must be relieved by right transverse colostomy before the area of inflammatory diverticulitis can be resected. On several occasions we have found that cecostomy is an effective means of decompressing the obstructed dilated colon, and in such cases definitive resection can be performed 10 to 14 days later, with little or no increased operative risk. In some cases, the Miller-Abbott tube has been most helpful in decompressing the large bowel, and preliminary colostomy has not been necessary. One-stage resection of diverticulitis should not be utilized in the presence of obstruction or severe inflammatory changes in the colon. A proximal colostomy established prior to resection is still a valuable method in acute cases of diverticulitis. Massive Bleeding The incidence of bleeding from diverticulitis is still indefinite and it is difficult to estimate an accurate rate of occurrence. Reports of massive hemorrhage from diverticulitis are increasing, but resection of the colon as an emergency measure for hemorrhage must be a rare procedure. It is difficult to demonstrate the source of bleeding in resected specimens. Gross bleeding occurred in 7 of 73 patients requiring surgical treatment and in none of these were emergency procedures employed. Thompson12 stated that bleeding can occur from diverticulitis alone in 25 per cent of cases. Judd 5 found six cases of massive hemorrhage in 68 consecutive resections. Hoar and Bernhard4 reported 42 instances (38 per cent) of massive hemorrhage in 111 cases of diverticulosis and diverticulitis. The existence of benign or malignant neoplasm must be excluded by sigmoidoscopy and x-ray examination before bleeding can be attributed to diverticulitis. Bleeding more often is recurrent, but we have seen patients with massive bleeding probably from diverticulitis who responded to conservative measures. We have resected the colon for massive bleeding in only two instances and, as stated above, the point of bleeding often cannot be recognized. Wilson13 reported five resections for significant bleeding in a group of 32 patients who had resections for complications of acute diverticulitis. Massive bleed-
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ing most frequently occurs in patients of an older age group (70 to 80 years) who are bad operative risks. In our experience, bleeding has ceased in most of these patients with conservative measures and very rarely has resection of the colon been necessary to control massive hemorrhage. When hemorrhage persists in elderly patients of the high-risk group, we prefer a transverse colostomy to divert the fecal stream. Occasionally, the colon involved with diverticula should be resected to control massive hemorrhage provided other sources of massive bleeding are excluded.
TECHNIQUE
One-stage colonic resection with primary anastomosis is employed more and more often by surgeons in this country, with practically no operative mortality and with greatly lowered morbidity. This one-stage resection also can be utilized after a preliminary colostomy has been established to manage serious complications such as peritonitis, abscess or fistula resulting from perforation of diverticula. The preparation of the colon before operation is most important. The bowel must be cleaned of all fecal matter by catharsis and irrigations. Sterilization of the colon by effective antibiotic agents such as neomycin and phthalylsulfathiazole (Sulfathalidine) has materially reduced morbidity and mortality. At present, we have used Neothalidine (Merck, Sharp & Dohme), 15 cc. every four hours for 48 hours, with very satisfactory results. Resection of the affected colon is carried out through a left rectus musclesplitting incision extending from the pubis to above the umbilicus. The colon is mobilized by dividing the lateral peritoneal reflection as high as necessary in order to permit primary anastomosis without tension; this may necessitate mobilization of the splenic flexure in some cases. The resection does not need to include scattered diverticula well above the segment involved with inflammatory changes since diverticulitis occurs in the sigmoid in 95 per cent of cases. Anastomosis of the divided ends of bowel is made using 0 chromic catgut for the mucosal layer and 3-0 interrupted silk for the serosal layer. The defect in the mesentery is closed with interrupted 3-0 silk to prevent herniation of the small bowel through the defect. It is seldom necessary to close the lateral peritoneum. On occasion, with a low transection of the sigmoid, we have found it somewhat easier to perform side-ofsigmoid to end-of-rectosigmoid anastomosis, which permits a wider stoma than does an end-to-end anastomosis in which the caliber of the sigmoid tends to be narrow. The length of hospital stay with a one-stage procedure after drainage and preliminary colostomy has been decreased to an average of 15 days. Wound infection and other complications resulting from sepsis are rare when patients are prepared meticulously for subsequent resection of the colon.
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SUMMARY Diverticulosis occurs in a larger segment of the population (10 to 20 per cent) after the age of 40 years. Diverticulitis will develop in 5 to 7 per cent of all cases of diverticulosis and require surgical intervention. Prophylactic resection during a quiescent period of diverticular disease of the colon is a justifiable procedure in decreasing not only the serious life-threatening complications but the morbidity also. Acute complications of diverticulitis demand immediate surgical intervention to prevent fatalities. While uncomplicated diverticulosis does not often give rise to serious symptoms or endanger life, there is always the possibility of perforation, abscess, massive hemorrhage or bowel obstruction. Roentgenologic examination of the colon after the age of 40 would provide life-saving information for patients who might later have an acute abdominal condition of obscure origin. Such information would be invaluable in the early differential diagnosis.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Bacon, H. E. and Magsanoc, C. M.: Am. J. Surg. 108: 830-833,1964. Barborka, C. J. and Texter, E. C., Jr.: S. CLIN. NORTH AMERICA 34: 209,1954. Boles, R. S., Jr. and Jordan, S. M.: Gastroenterology 35: 579, 1958. Hoar, C. S. and Bernhard, W. F.: Surg. Gynec. & Obst. 99: 101, 1954. Judd, E. S., Jr. and Mears, T. W.: Arch. Surg. 70: 818, 1955. Judd, E. S. and Waugh, J. M.: Abdominal Surgery. Allen and Barrow. New York, Paul B. Hoeber, 1961, pp. 591-603. Leis, H. P.: Hospital Medicine, pp. 16-21 (Feb.) 1965. Mailor, R.: Lancet 2: 51, 1928. Marshall, S. F.: Am. Surgeon 29: 337-346, 1963. Muir, E. G.: Tr. M. Soc. London 72: 164,1956. Ransom, R. K.: Gastroenterology 26: 51, 1928. Thompson, H. R.: Abdominal Operations. Maingot. Appleton-Century-Crafts, 4th ed., 1961, pp. 1125-1141. Wilson, F. C.: Tr. South. S. A. 84: 410-414, 1962.
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Diverticulosis of the colon is a pathologic condition which consists of numerous diverticula in the wall of the colon. These diverticula may be scattered throughout the entire length of the colon but are found most frequently in the sigmoid colon. When they become inflamed, the process is termed diverticulitis. Complications of diverticulitis are common and often their treatment is urgent; immediate surgical intervention is often necessary to avoid serious sequelae and even death. Diverticula are small pouches that arise in the wall of the colon; the thin pouch wall is made up of mucosa covered with peritoneum. The small hernial sacs occur along arteries which penetrate the peritoneum to the mucosa, and are commonly found at the antimesenteric surface of the colon between the taenial bands where the colon is deficient in longitudinal muscle.
INCIDENCE
The incidence of diverticulosis is fairly high. Its incidence in patients who have radiologic examinations for gastrointestinal disease is reported to be 15 to 20 per cent. Ransom ll stated that in approximately 15,000 x-ray examinations, diverticula were noted in one of every eight patients. Thompsonll reported that 500 deaths in England and Wales each year are caused by diverticulitis of the colon. Bllrborka2 reported that diverticulitis was uncommon in patients under the age of 40 but that 5 to 20 per cent of patients more than 40 years of age had diverticula and diverticulitis developed in 15 to 20 per cent of this group. The colonic segment most involved in diverticulosis is the sigmoid and
* Staff, New England Baptist and New England Deaconess Hospitals, Boston, Massachusetts
** Associate Surgeon, New England Baptist Hospital.
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descending colon. Judd and Waugh 6 stated that diverticulitis was present only in the sigmoid in 98 per cent of cases. Mailor 8 in a necropsy study reported that diverticula occurred in the sigmoid in 40 per cent of cases and in the entire colon in 30 per cent. In a group of 294 cases studied by Boles3 the diverticula were in the cecum in 2 per cent and in the sigmoid and descending colon in 55 per cent. The entire colon was involved in 33 per cent. Sex seems to have little influence on frequency and occurrence of this disease. The sex incidence was about equal in Boles' series-134 men and 160 women. However, most authorities quote a slightly higher incidence in men.
THERAPEUTIC INDICATIONS In patients who have uncomplicated diverticulosis, severe symptoms do not develop nor does the condition endanger life. The complications of diverticulitis, however, account for severe abdominal distress and serious illness, and may be associated with a high mortality. The complications of diverticulosis and diverticulitis can often be prevented by instituting a careful dietary and medical regimen early in those patients with diverticulosis; in 80 per cent the diverticulosis can be managed medically and only a small percentage will ultimately require operation. Surgical treatment can be utilized with a great margin of safety if the operation is not postponed until more serious complications-even sequelae that may cause deatharise. Leis 7 stated that diverticulitis develops in 10 to 20 per cent of persons with diverticulosis, and will require operation. In Boles' study of 294 patients with diverticulosis, diverticulitis developed in 73 but only 16 required surgical intervention. In a more recent consecutive series of patients whom we 9 have operated on, 7 of 20 patients who had resections for diverticulitis required immediate operation for complications such as abscess, perforation or subacute obstruction of the colon. Many patients have had previous attacks of acute diverticulitis that subsided under conservative management. One attack of inflammation does not forecast future attacks, but without good medical care, diverticulitis tends to recur and more extensive alterations of the colon are found, with a higher incidence of serious complications, most frequently in the form of an inflammatory tumor mass or stricture of the colon with obstru ction. Repeated attacks of diverticulitis usually result in complications that require operation. In our experience, complications of diverticulitis, such as obstruction, perforation and bleeding, occurred in 22.5 per cent of patients who had only one attack, whereas these complications were found in 57.5 per cent of patients who had had more than one attack. Diverticular disease of the colon, either diverticulosis or diverticulitis, occurs frequently, with about 5 to 7 per cent of patients requiring operative treatment for relief of symptoms. All too often in the past, surgical treatment was used only for patients with serious complications, and multiple-stage operations were
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employed in most instances. Today, elective surgery, consisting of one-stage colon resection, can be done during an inactive phase of the inflammatory process with almost no operative mortality. However, in a small percentage of cases the existence of diverticular disease is not suspected until a serious complication develops that may result in fatality. Baconl strongly advocated prophylactic resection as definitive therapy for diverticulitis in an effort to avoid emergency operation for the serious complications that may carry a high operative mortality. In his experience with 326 patients, 11.3 per cent required emergency procedures, with a mortality of 8.1 per cent. In our own experience 9 during a six-year period (January 1954 to January 1960) of 180 resections performed for diverticulitis, none was an emergency procedure. The last consecutive 118 patients (65.5 per cent of the entire series) had one-stage resections with no operative deaths. In an effort to prevent the more serious complications and in view of the high incidence of diverticular disease after the age of 40, every patient more than 40 years of age should have a barium enema examination to disclose the presence of diverticular disease and to alert the physician to the possibility that diverticulitis may be the cause of an acute abdominal catastrophe. Previous x-ray studies are a valuable record and help immeasurably in the accurate determination of the etiology of an acute abdominal condition.
COMPLICATIONS OF DIVERTICULOSIS AND DIVERTICULITIS
Complications of diverticulosis that often demand emergency operations are perforation of a diverticulum, localized abscess, a spreading or generalized peritonitis, massive bleeding, colon or small bowel obstruction, and portal pyemia or liver abscess. Acute obstruction of the small intestine may occur but distinction must be made between paralytic ileus and a true obstruction. Paralytic ileus frequently occurs with spreading peritonitis. Other complications rarely demand immediate surgical intervention-acute diverticulitis, rarely acute colonic obstruction or acute colovesical fistula. Occasionally acute obstruction of the colon will result from carcinoma and at times in the differential diagnosis it may be difficult to determine whether acute diverticulitis or carcinoma is the cause of the obstruction. Muir'slo experience and opinion are well worth citing: "The clinical course is usually longer in diverticulitis. Patients with diverticulitis are usually obese but with carcinoma there is often a history of weight loss. Pain is more common in diverticulitis and is recurrent. Alteration of bowel habit is more characteristic of carcinoma. Elevated temperature and leukocytosis are more apt to be present with diverticulitis. Rectal bleeding recurs in 20 per cent of diverticulitis but is persistent with carcinoma and rarely massive in the latter. Palpable tumor may occur with both diseases but is more apt to be tender in diverticulitis."
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Figure 1 (Case I). Man aged 84 years. Obstruction of sigmoid due to diverticulitis with repeated attacks. Numerous diverticula throughout sigmoid colon with marked narrowing of sigmoid.
Concomitant Tumor Carcinoma occasionally coexists with diverticulitis but there is no evidence that carcinoma develops because of inflammation of the colon from diverticulitis. CASE I. An 84 year old physician, known to have diverticulosis which had been treated medically for years, was admitted because of increasing pain in the left lower quadrant and decrease in the size of his stools, with 2 episodes of obstruction of the large intestine. A barium enema study (Fig. 1) revealed numerous diverticula throughout the sigmoid colon and to a lesser extent involving the descending colon. The roentgenogram also showed marked narrowing of the sigmoid colon. After careful preparation of the bowel, a primary resection of the sigmoid colon was performed. In addition to the diverticulosis and acute diverticulitis with marked narrowing of the sigmoid colon, a polypoid carcinoma was found which measured 3 by 2 by 1.5 em., and was suspended by a 2 by 2 cm. stalk. Pathologic evidence of metastasis was not present. The postoperative course was without incident. The stools returned to normal size, and he has been asymptomatic for 3 years.
This is a good illustration of diverticulitis with a concomitant carcinoma. Carcinoma may be difficult to demonstrate by both proctoscopy and barium enema study, and in this case it was not demonstrated on the roentgenogram.
Perforation with Small Bowel Obstruction In all complications of suspected diverticular disease a roentgenogram of the abdomen should be made in every case and may need to be repeated each day if operation is postponed. X-ray examination of the abdomen has
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helped us considerably to recognize the development of small bowel obstruction from adherence and kinking of the bowel at the point of diverticular leakage. CASE II. A 52 year old obese man, known to have diverticulosis, was hospitalized because of sudden onset of pain in the lower part of the abdomen 20 hours before admission. The abdomen was distended and tenderness was elicited across
Figure 2 (Case II). Man aged 52 years. A, Acute perforation (24 hours) with development of acute small bowel obstruction. X-ray of abdomen showed dilated loops of small intestine which on lateral decubitus show air-fluid levels. B, X-ray 24 hours later with oral Gastrografin. Obstruction of small intestine overlying 5th lumbar vertebra with evidence of extrinsic pressure at the point.
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the lower part of the abdomen, especially in the left lower quadrant. He was nauseated but vomiting had not occurred. The temperature was 101.4° F., the hemoglobin 15.8 gm., and the white blood cell count 18,000. A roentgenogram of the abdomen showed distention of the small bowel and multiple fluid levels in the upright position. Roentgenograms of the abdomen on 2 successive days, using Gastrografin, showed evidence of increasing partial obstruction of the small intestine overlying the fifth lumbar vertebra (Fig. 2). There was extrinsic pressure on the inferior aspect of the small intestine at this point, suggesting an inflammatory mass. Operation revealed a perforated diverticulum of the sigmoid colon just to the right of the midline and posterior to the urinary bladder. The perforation was localized to this area, and the terminal ileum was obstructed by its adherence to the area of perforation. This obstruction was located approximately 18 inches (45 cm.) proximal to the ileocecal valve. A surrounding localized abscess was found which contained several milliliters of thin, watery, purulent fluid. Lysis of the intimate attachment of the small bowel to the perforated diverticulum released the small intestinal obstruction. The pelvic abscess was drained.
This case is an example of small bowel obstruction occurring as a result of an acute perforation of a diverticulum of the sigmoid colon. Sigmoidoscopic examination may be helpful in a few cases in ruling out perforated carcinoma of the colon, but the diverticular opening in the bowel is rarely visualized. The sigmoidoscope usually encounters obstruction 12 to 15 cm. from the anal margin, and further insert.ion may be very painful because of adherence and angulation of the inflammatory mass of bowel. Most carcinomas, however, can be visualized with proctoscopy, permitting the physician to obtain tissue for biopsy. The rectosigmoid can be outlined with Gastrografin given by enema, but such an examination should be performed cautiously because of the possibility that the diverticulum is perforated. This examination has helped occasionally when the differential diagnosis is difficult.
Perforation with Abscess Formation Perforation of the colon is the more common complication in diverticulitis and demands surgical intervention. The diagnosis should be suspected in an obese individual with known diverticulosis. The perforation may be free, with a rapidly spreading peritonitis, but more often there is slow leakage with localized peritoneal inflammation. The adjacent viscera and omentum may seal off the area of slow leakage, with formation of an abscess. Very often the patient is not referred to the surgeon at once and a few days may elapse so that a local abscess is present when the surgeon is consulted. CASE III. A 62 year old man was hospitalized because of pain and localized tenderness in the left lower quadrant occurring one week before admission. An abscess was incised and drained, and a large amount of purulent drainage was obtained. Because of the adherence of loops of bowel and no evidence of obstruction, colostomy was not attempted. A fecal fistula resulted, as anticipated, but obstruction did not develop. A subsequent barium enema study showed diverticulitis of the sigmoid colon with perforation (Fig. 3).
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Figure 3 (Case III). Man aged 62 years. Perforated diverticulum with abscess. X-ray shows many diverticula with sinus tract at site of perforation. Abscess drained with resection of sigmoid at later date.
Three months later the patient was readmitted for elective resection. A persistent fecal fistula was present. The fistula was excised, and an anterior resection of the sigmoid colon was performed, with end-to-end anastomosis.
This case illustrates diverticulitis of the sigmoid colon with perforation and formation of an abscess which was drained, with resulting fecal fistula. An anterior resection of the perforation of the sigmoid and fecal fistula was performed at a later date after the acute process had subsided. Left-sided localization suggests strongly the diagnosis of perforated diverticula. The extreme cellulitis resulting from the perforation may cause further perforation into the bladder or adjacent viscera. X-ray visualization of air collections is not usual unless free perforation is present, and with a rapidly spreading peritonitis the presence of free air in the abdomen is more suggestive of perforated ulcer. Perforation of a solitary diverticulum on the right side may simulate acute appendicitis. CASE IV. A 69 year old woman was admitted in January, 1965 because of pain in the right lower quadrant which became progressively more severe and was associated with nausea and vomiting. A large mass was palpated in the right lower quadrant. Barium enema study showed multiple diverticula present throughout the entire colon (Fig. 4). The cecum appeared spastic and did not fill well. At operation a perforation of the cecum was found, with gangrene of the cecum and
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Figure 4 (Case IV). Woman aged 69 years. A, X-ray of colon shows multiple diverticula present throughout colon. B, Perforation of diverticulum of cecum. Inflammatory mass involving cecum. Cecum spastic and did not fill well with barium. Resection January, 1965. C, June, 1965. Perforated diverticulitis of sigmoid colon with fistula into small intestine in left lower quadrant. Operation consisted of closure of opening into small intestine and resection of sigmoid. December, 1965, patient well.
a large, unusual type of fecalith measuring 3.5 by 3 by 1.5 cm., which lined a large tract entering a closed cystic cavity. The terminal ileum was involved in this mass. In addition, diverticulitis of the sigmoid colon was noted with marked thickening of the sigmoid and an associated diverticular mass. Inasmuch as x-ray evidence of sigmoid obstruction was not present, it was thought unwise to perform a multiple procedure. In March, 1965, some 3 months after operation, the patient was readmitted because of severe pain and tenderness in the left lower quadrant. A diagnosis was made of perforation of the sigmoid colon. At operation, a walled-off perforation of a diverticulum of the midsigmoid was found, with marked reduction in the size of the lumen. A primary anterior resection was carried out. After operation, an intra-abdominal abscess developed, which was drained, and a fistula of the abdominal wall developed. Roentgenograms showed a fistulous communication between the distal jejunum and the sigmoid colon at the anastomotic site. Her general condition improved, and the small bowel drainage decreased somewhat. Arrangements were made for readmission at a later date if the fistula did not close spontaneously, and the patient was discharged. The patient was readmitted in June, 1965 because of severe pain in the left lower quadrant, and was prepared for excision of the persistent fistulous tract. It should be noted that during the past 272 months she continued to have pain in the
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left lower quadrant. At operation, diverticulitis and fistulas of the small bowel were found. The sigmoid colon was again resected and the fistulas were simply closed. Following this procedure she did extremely well. There was no evidence of wound infection, and upon discharge from the hospital she was having normal bowel movements. This case is an example of multiple diverticula with perforation of both the right and left colon. Solitary cecal diverticula are usually congenital and have considerable tendency toward inflammation and perforation. Multiple diverticula, however, occur in the cecum and ascending colon; in Boles' experience 2 per cent were located in the cecum. Perforation of diverticula, with a long pelvic sigmoid lying on the right side, may suggest acute appendicitis. The differential diagnosis of a gangrenous appendix and a perforated diverticulum of the pelvic colon may not be easy and may be established accurately only by laparotomy. We have recently had a patient with an abscess in the right side of the pelvis resulting from perforation of a diverticulum of the sigmoid colon, but the diagnosis was apparent because this patient had had an appendectomy previously. Because of the difficulty in diagnosis in right-sided inflammation, the need for immediate surgical intervention is apparent. Perforation with Spreading Peritonitis
Operation is urgently needed in instances of spreading peritonitis with perforation of a diverticulum. If the patient is seen at the onset of perforation, we believe operation is imperative, but if he is seen 8 to 12 hours after perforation, and peritonitis is localized, with abscess formation, surgery can best be deferred and the abscess drained safely at a later date. If localization does not occur, a generalized peritonitis and paralytic ileus will develop. Surgery should consist of proximal colostomy and drainage of the area of perforation. Usually, any attempt to suture the perforation is futile because of induration and edema, and suture of the fatty epiploica over the perforation is impossible since sutures will not hold in such a cellulitis. Fecal fistulas develop in most cases but, when a proximal colostomy has been established, resection can be carried out readily at a later date without undue operative risk. If the peritonitis has localized and operation is deferred, a resultant abscess can be drained safely at a more favorable time. With the development of general peritonitis from free perforation of diverticulitis, occasionally a subhepatic, subphrenic or liver abscess will be encountered. The occurrence of such abscesses should always be considered if a septic course continues, and if an abscess is found, it should be drained. The exercise of surgical judgment is difficult in all cases of perforated diverticulitis of the colon. In acute cases of colovesical fistulas, proximal colostomy is necessary. This can be done through a left muscle-splitting incision, using the descending colon for colostomy. Later, after careful preparation of the colon, the vesical fistula can be closed and the colonic stoma excised through the same incision, thus permitting a one stage resec-
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tion of the colon without increased operative risk. We prefer this method of establishing a proximal colostomy since an additional operative stage for closure of the colostomy can be avoided. If the descending colon cannot be mobilized enough to permit formation of a divided colostomy, the colostomy may be made in the transverse colon even if it is necessary to extend the left rectus incision to form the colostomy. After perforation, a definitive operation can usually be performed within three months. Simple closure of a colostomy without resection of the colon is to be condemned, since it will result in recurrence of diverticulitis in more than 80 per cent of cases. Intestinal obstruction resulting from diverticulitis is usually subacute or chronic and there is a history of repeated attacks of diverticulitis. Occasionally, however, complete obstruction does occur. In such cases, the obstruction must be relieved by right transverse colostomy before the area of inflammatory diverticulitis can be resected. On several occasions we have found that cecostomy is an effective means of decompressing the obstructed dilated colon, and in such cases definitive resection can be performed 10 to 14 days later, with little or no increased operative risk. In some cases, the Miller-Abbott tube has been most helpful in decompressing the large bowel, and preliminary colostomy has not been necessary. One-stage resection of diverticulitis should not be utilized in the presence of obstruction or severe inflammatory changes in the colon. A proximal colostomy established prior to resection is still a valuable method in acute cases of diverticulitis. Massive Bleeding The incidence of bleeding from diverticulitis is still indefinite and it is difficult to estimate an accurate rate of occurrence. Reports of massive hemorrhage from diverticulitis are increasing, but resection of the colon as an emergency measure for hemorrhage must be a rare procedure. It is difficult to demonstrate the source of bleeding in resected specimens. Gross bleeding occurred in 7 of 73 patients requiring surgical treatment and in none of these were emergency procedures employed. Thompson12 stated that bleeding can occur from diverticulitis alone in 25 per cent of cases. Judd 5 found six cases of massive hemorrhage in 68 consecutive resections. Hoar and Bernhard4 reported 42 instances (38 per cent) of massive hemorrhage in 111 cases of diverticulosis and diverticulitis. The existence of benign or malignant neoplasm must be excluded by sigmoidoscopy and x-ray examination before bleeding can be attributed to diverticulitis. Bleeding more often is recurrent, but we have seen patients with massive bleeding probably from diverticulitis who responded to conservative measures. We have resected the colon for massive bleeding in only two instances and, as stated above, the point of bleeding often cannot be recognized. Wilson13 reported five resections for significant bleeding in a group of 32 patients who had resections for complications of acute diverticulitis. Massive bleed-
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ing most frequently occurs in patients of an older age group (70 to 80 years) who are bad operative risks. In our experience, bleeding has ceased in most of these patients with conservative measures and very rarely has resection of the colon been necessary to control massive hemorrhage. When hemorrhage persists in elderly patients of the high-risk group, we prefer a transverse colostomy to divert the fecal stream. Occasionally, the colon involved with diverticula should be resected to control massive hemorrhage provided other sources of massive bleeding are excluded.
TECHNIQUE
One-stage colonic resection with primary anastomosis is employed more and more often by surgeons in this country, with practically no operative mortality and with greatly lowered morbidity. This one-stage resection also can be utilized after a preliminary colostomy has been established to manage serious complications such as peritonitis, abscess or fistula resulting from perforation of diverticula. The preparation of the colon before operation is most important. The bowel must be cleaned of all fecal matter by catharsis and irrigations. Sterilization of the colon by effective antibiotic agents such as neomycin and phthalylsulfathiazole (Sulfathalidine) has materially reduced morbidity and mortality. At present, we have used Neothalidine (Merck, Sharp & Dohme), 15 cc. every four hours for 48 hours, with very satisfactory results. Resection of the affected colon is carried out through a left rectus musclesplitting incision extending from the pubis to above the umbilicus. The colon is mobilized by dividing the lateral peritoneal reflection as high as necessary in order to permit primary anastomosis without tension; this may necessitate mobilization of the splenic flexure in some cases. The resection does not need to include scattered diverticula well above the segment involved with inflammatory changes since diverticulitis occurs in the sigmoid in 95 per cent of cases. Anastomosis of the divided ends of bowel is made using 0 chromic catgut for the mucosal layer and 3-0 interrupted silk for the serosal layer. The defect in the mesentery is closed with interrupted 3-0 silk to prevent herniation of the small bowel through the defect. It is seldom necessary to close the lateral peritoneum. On occasion, with a low transection of the sigmoid, we have found it somewhat easier to perform side-ofsigmoid to end-of-rectosigmoid anastomosis, which permits a wider stoma than does an end-to-end anastomosis in which the caliber of the sigmoid tends to be narrow. The length of hospital stay with a one-stage procedure after drainage and preliminary colostomy has been decreased to an average of 15 days. Wound infection and other complications resulting from sepsis are rare when patients are prepared meticulously for subsequent resection of the colon.
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SUMMARY Diverticulosis occurs in a larger segment of the population (10 to 20 per cent) after the age of 40 years. Diverticulitis will develop in 5 to 7 per cent of all cases of diverticulosis and require surgical intervention. Prophylactic resection during a quiescent period of diverticular disease of the colon is a justifiable procedure in decreasing not only the serious life-threatening complications but the morbidity also. Acute complications of diverticulitis demand immediate surgical intervention to prevent fatalities. While uncomplicated diverticulosis does not often give rise to serious symptoms or endanger life, there is always the possibility of perforation, abscess, massive hemorrhage or bowel obstruction. Roentgenologic examination of the colon after the age of 40 would provide life-saving information for patients who might later have an acute abdominal condition of obscure origin. Such information would be invaluable in the early differential diagnosis.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Bacon, H. E. and Magsanoc, C. M.: Am. J. Surg. 108: 830-833,1964. Barborka, C. J. and Texter, E. C., Jr.: S. CLIN. NORTH AMERICA 34: 209,1954. Boles, R. S., Jr. and Jordan, S. M.: Gastroenterology 35: 579, 1958. Hoar, C. S. and Bernhard, W. F.: Surg. Gynec. & Obst. 99: 101, 1954. Judd, E. S., Jr. and Mears, T. W.: Arch. Surg. 70: 818, 1955. Judd, E. S. and Waugh, J. M.: Abdominal Surgery. Allen and Barrow. New York, Paul B. Hoeber, 1961, pp. 591-603. Leis, H. P.: Hospital Medicine, pp. 16-21 (Feb.) 1965. Mailor, R.: Lancet 2: 51, 1928. Marshall, S. F.: Am. Surgeon 29: 337-346, 1963. Muir, E. G.: Tr. M. Soc. London 72: 164,1956. Ransom, R. K.: Gastroenterology 26: 51, 1928. Thompson, H. R.: Abdominal Operations. Maingot. Appleton-Century-Crafts, 4th ed., 1961, pp. 1125-1141. Wilson, F. C.: Tr. South. S. A. 84: 410-414, 1962.
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