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Surgical Treatment for Diverticulitis
Surgical Treabnent for Diverticulitis BENTLEY P. COLCOCK, M.D.
There are few conditions in the abdomen which test the skill and judgment of a surgeon more than diverticulitis of the colon. These patients are usually elderly; often they are obese. If the resection does not include all of the inflamed bowel, if many diverticula are present at the cut margin, or if the anastomosis is carried out under tension, an abscess with subsequent fistula formation or stenosis is likely to develop. A complication such as this means complete failure of the operative procedure. Sometimes it results in a fatality. On the other hand, overconservatism on the part of the surgeon commits the patient to a long and costly illness. The inflammatory process in diverticulitis varies greatly from patient to patient. There are no hard and fast rules for operative technique. Nevertheless, from experience it becomes evident that certain procedures, under certain circumstances, involve definite hazards. The surgeon's first objective is to bring his patient safely through this serious illness. His second objective is to cure the patient in the shortest possible time. The mortality rate for the surgical treatment of diverticulitis should be under 2 per cent.
INDICATIONS FOR SURGERY
PERSISTENT OR RECURRENT DIVERTICULITIS. Persistent or recurrent symptoms of diverticulitis are, and should be, the most common indication for surgery in this disease. These patients can usually be completely relieved of symptoms by a single operative procedure and recurrence is rare. We know from experience that when the disease persists or recurs, a complication, such as perforation or obstruction, is very likely to develop. If the disease is allowed to go on to perforation or obstruction, the mortality and the morbidity rates are increased. When surgical resection of the diseased bowel is carried out at this stage, not only are these serious complications avoided but an unsuspected carcinoma is less likely to be overlooked. Moreover, a primary resection can be carried out with the same low mortality rate that is associated with the staged operations in patients with complicated diverticulitis. 667
668
BENTLEY
P.
COLCOCK
PERFORATION. Perforation is the next most common indication for surgery in diverticulitis. If the perforation results in diffuse peritonitis or a large abscess, the patient's best chance for survival lies in an immediate diversion of the fecal stream by a transverse colostomy. A small, wellcontained abscess will often subside under conservative treatment and permit carrying out an elective one-stage resection at a later date. FISTULA. Colovesical, colovaginal and colo cutaneous fistulas are common complications of diverticulitis of the colon. The operative procedure will depend upon the extent of the inflammatory reaction surrounding the fistula. If it is not extensive, the inflammatory mass can be dissected free from the bladder, the bladder closed, and a primary resection carried out. On the other hand, if the fistula is associated with a large inflammatory mass, a transverse colostomy should be done and the inflammation allowed to subside. The resection can then be carried out with very little risk and with few serious complications. OBSTRUCTION. With persistence or recurrence of the diverticulitis, complete or almost complete obstruction of the sigmoid may occur. Complete obstruction of the large bowel is a serious condition in an obese, elderly patient. A dilated, distended colon cannot be sutured with safety and a proximal colostomy is the only procedure indicated. To RULE OUT CARCINOMA. Both carcinoma of the colon and diverticulitis of the colon occur in the same age group and often the symptoms are similar. Both conditions occur most frequently in the sigmoid colon. Thus, the two diseases may coexist, or one may be mistaken for the other. If carcinoma cannot be definitely excluded, the patient must be operated on promptly. At operation, the history, the barium enema study and the appearance of the lesion are carefully considered in making a tentative diagnosis for or against cancer. If the tentative diagnosis is diverticulitis and the inflammatory reaction is extensive, a transverse colostomy may be done. A barium enema study should then be repeated within two to three weeks and the question of the presence of carcinoma again considered. If it still cannot be excluded, resection must be performed. If the diagnosis is probable diverticulitis but resection is feasible, this is the procedure of choice. If a conservative resection is carried out in the belief that the lesion is inflammatory, the bowel should be opened before the abdomen is closed. The presence of carcinoma will be recognized immediately upon opening the bowel and a more radical resection then performed. If it is the surgeon's opinion, based on all of the factors involved, that the lesion in all likelihood is carcinoma, a radical resection should be the initial procedure. BLEEDING. In recent years serious bleeding has become a more frequent indication for surgery in diverticulitis. In many instances, however, bleeding will stop with conservative treatment and blood replacement. Surgical intervention is indicated only when bleeding is persistent and profuse. It should be remembered that serious bleeding may occur in patients who have diverticulosis with no clinical or x-ray evidence of
SURGICAL TREATMENT FOR DIVERTICULITIS
669
inflammatory reaction in the colon. If the process is localized to a segment of the colon, such as the sigmoid, this area is resected. When the bleeding is associated with diverticulosis which involves the entire colon, and if no visible or palpable evidence of an inflammatory reaction can be found, a transverse colostomy may be carried out. If rectal bleeding continues but there is no bleeding from the proximal colon, the bleeding can be controlled by resection of the distal colon and total colectomy is thus avoided. Bleeding in a patient with diverticulitis, particularly if it is persistent but not profuse, is always an indication to make sure that carcinoma has been ruled out.
TECHNIQUE
Colostomy
The colostomy should be established in the mid or proximal transverse colon (Fig. 1). This will permit easy mobilization of the splenic flexure should it be necessary at the subsequent resection. The incision is placed in the right upper quadrant so that the colostomy is well removed from the area of the second incision. It is important that the area of the perforation (or fistula) be completely defunctionalized. This means that feces should not pass over into the distal colon. The most effective way to do this is to divide the bowel completely at the time the colostomy is made. There is a tendency for the mobile transverse colon to prolapse unless the mesentery is securely fixed to the abdominal wall. The great omentum must, of course, be detached at the point where the bowel is exteriorized. The exteriorized colon may be supported by a glass or metal rod and divided later with the cautery. I prefer to divide it immediately between Ochsner clamps and to decompress the proximal limb by a catheter if significant dilatation is present. If a large abscess is present in the left lower quadrant, drainage by an extraperitoneal approach will hasten resolution of the abscess. Closure of Colostomy
Except in rare instances, the colostomy should not be closed before resection of the diseased bowel is carried out. Recurrence of symptoms and probably a recurrence of the complication (perforation or obstruction) are likely to occur. The length of time that should elapse before resection is carried out will vary according to the extent of the inflammatory reaction which was present at the time the colonic stoma was established. If the presence of carcinoma has been ruled out, the longer the inflammatory reaction is allowed to subside the easier will be the subsequent resection. The chance of serious postoperative complications after resection will also be reduced. As a general rule, if a large inflammatory mass is present at the time of colostomy, resection should be delayed for at least four months.
670
BENTLEY
P.
COLCOCK
Figure 1. A, A portion of the proximal transverse colon has been exteriorized and completely divided. The shaded area indicates the segment of colon involved with acute diverticulitis, often associated with a large pericolic abscess. B, After the fecal etream has been completely diverted for four to six months, the inflammatory process will subside, leaving a shrunken, scarred, but otherwise normal sigmoid colon. C, The diseased segment of colon has been removed. The ends can be approximated without tension due to mobilization of the splenic flexure. The circle above indicates the restoration of intestinal continuity by an end-to-end anastomosis as soon as the colorectal anastomosis has healed.
With encouragement and the use of a plastic colostomy appliance, most of these patients will return to work during this interval. If the inflammatory reaction has completely subsided at the time of resection, closure of the colostomy at the same operation may be considered. It should not be done, however, unless the surgeon is completely satisfied with the anastomosis. A small leak at the anastomosis will do no harm if a proximal colostomy is present. If the colostomy has been closed, a leak will lead to abscess formation, which will require incision and drainage and
SURGICAL TREATMENT FOR DIVERTICULITIS
671
a second colostomy. It is safer to close the colostomy two to three weeks after the resection. If considerable inflammatory reaction was present in the bowel wall at the time of the resection and anastomosis, closure of the colostomy should be delayed for one to two months. Under these circumstances it is well to do a barium enema study before closing the colostomy. The colostomy may be closed despite extravasation of a small amount of barium at the suture line. It is important, however, to be sure that stenosis of the anastomosis is not present.
Resection If a primary one-stage resection (Fig. 2) is planned, the bowel is prepared before operation. Colonic irrigations and the usual laxative are omitted because of the danger of perforation. Phthalylsulfathiazole (Sulfathalidine), 1 gm., and neomycin, 0.5 gm., are given every six hours for 36 to 48 hours. If a colostomy is already present, bowel preparation consists of irrigation of the distal segment of colon with the neomycin solution. A left paramedian incision is used, reflecting the left rectus muscle. The incision must frequently be long enough to permit mobilization of the splenic flexure and the construction of an anastomosis just above the symphysis pubis. The paramedian incision will permit preservation of the blood supply and nerve supply to the rectus muscle. A primary one-stage resection is hazardous unless all of the inflamed colon is removed. Leakage is also likely to occur if the anastomosis is made through a segment con-
A
Figure 2. A, The posterior walls of the proximal and of the distal segments have been approximated with interrupted sutures of silk. B, The mucosal and submucosal layers of the posterior wall are united with interrupted sutures of silk or fine catgut. The anterior wall of the colon and rectum is sutured in a similar manner.
6-72
BENTLEY
P.
COLCOCK
Figure 3. Primary resection for diverticulitis. The acutely inflamed segment of colon is dissected free of its attachments and resected. Sufficient bowel should be resected on both sides of the lesion so that normal colon can be approximated to normal rectum, as shown on the right. Whether or not the splenic flexure will need to be mobilized will depend upon the extent of the inflammatory process. There must be no tension upon the suture line.
taining many diverticula. The two ends must be brought together without tension. Anyone or more of these factors will determine the need for mobilization of the splenic flexure. Suction apparatus should be available in case a small abscess is encountered as the colon is mobilized. The left ureter is likely to be adherent to the posterior surface of the involved sigmoid. Diverticulitis does not involve the rectum except secondarily. Unless it has been damaged by previous inflammation or previous surgery, normal rectum will be found to form the distal part of the anastomosis. The superior hemorrhoidal artery and vein are preserved unless carcinoma has not been excluded. It is always well to have the resected bowel opened as soon as it has been removed, even when the process is thought to be entirely inflammatory. Carcinoma of the sigmoid can be recognized immediately upon opening the bowel and a more radical resection of the mesentery carried out. The anastomosis may be made by anyone of several methods. I prefer an end-to-end anastomosis using only interrupted sutures so as to
SURGICAL TREATMENT FOR DIVERTICULITIS
673
obtain as large a lumen as possible (Fig. 3). The descending colon will usually cover the denuded left lumbar gutter, and reperitonealization is rarely necessary. This is particularly true if the splenic flexure has been mobilized. If the surgeon is concerned for any reason about the integrity of the anastomosis, he should protect it with a proximal transverse colostomy. It cannot be emphasized too strongly that a cecostomy is not adequate to protect an insecure anastomosis of the distal colon. A proximal colostomy is not used routinely.
SUMMARY
Deaths still occur from peritonitis secondary to a perforated diverticulum of the colon. Death may occur within 24 hours of the onset of symptoms. Patients with acute diverticulitis need intensive supportive treatment, fluids, electrolytes, and antibiotics. These, however, are not adequate substitutes for a prompt diversion of the fecal stream by transverse colostomy if signs of peritonitis are present. Serious complications and even a fatality may occur as the result of carrying out a resection in the presence of acute inflammation. With careful selection of cases for primary resection and meticulous technique with both the multiple and the single stage procedures, the mortality and morbidity rates for the surgical treatment of diverticulitis can be kept at a very low figure.
There are few conditions in the abdomen which test the skill and judgment of a surgeon more than diverticulitis of the colon. These patients are usually elderly; often they are obese. If the resection does not include all of the inflamed bowel, if many diverticula are present at the cut margin, or if the anastomosis is carried out under tension, an abscess with subsequent fistula formation or stenosis is likely to develop. A complication such as this means complete failure of the operative procedure. Sometimes it results in a fatality. On the other hand, overconservatism on the part of the surgeon commits the patient to a long and costly illness. The inflammatory process in diverticulitis varies greatly from patient to patient. There are no hard and fast rules for operative technique. Nevertheless, from experience it becomes evident that certain procedures, under certain circumstances, involve definite hazards. The surgeon's first objective is to bring his patient safely through this serious illness. His second objective is to cure the patient in the shortest possible time. The mortality rate for the surgical treatment of diverticulitis should be under 2 per cent.
INDICATIONS FOR SURGERY
PERSISTENT OR RECURRENT DIVERTICULITIS. Persistent or recurrent symptoms of diverticulitis are, and should be, the most common indication for surgery in this disease. These patients can usually be completely relieved of symptoms by a single operative procedure and recurrence is rare. We know from experience that when the disease persists or recurs, a complication, such as perforation or obstruction, is very likely to develop. If the disease is allowed to go on to perforation or obstruction, the mortality and the morbidity rates are increased. When surgical resection of the diseased bowel is carried out at this stage, not only are these serious complications avoided but an unsuspected carcinoma is less likely to be overlooked. Moreover, a primary resection can be carried out with the same low mortality rate that is associated with the staged operations in patients with complicated diverticulitis. 667
668
BENTLEY
P.
COLCOCK
PERFORATION. Perforation is the next most common indication for surgery in diverticulitis. If the perforation results in diffuse peritonitis or a large abscess, the patient's best chance for survival lies in an immediate diversion of the fecal stream by a transverse colostomy. A small, wellcontained abscess will often subside under conservative treatment and permit carrying out an elective one-stage resection at a later date. FISTULA. Colovesical, colovaginal and colo cutaneous fistulas are common complications of diverticulitis of the colon. The operative procedure will depend upon the extent of the inflammatory reaction surrounding the fistula. If it is not extensive, the inflammatory mass can be dissected free from the bladder, the bladder closed, and a primary resection carried out. On the other hand, if the fistula is associated with a large inflammatory mass, a transverse colostomy should be done and the inflammation allowed to subside. The resection can then be carried out with very little risk and with few serious complications. OBSTRUCTION. With persistence or recurrence of the diverticulitis, complete or almost complete obstruction of the sigmoid may occur. Complete obstruction of the large bowel is a serious condition in an obese, elderly patient. A dilated, distended colon cannot be sutured with safety and a proximal colostomy is the only procedure indicated. To RULE OUT CARCINOMA. Both carcinoma of the colon and diverticulitis of the colon occur in the same age group and often the symptoms are similar. Both conditions occur most frequently in the sigmoid colon. Thus, the two diseases may coexist, or one may be mistaken for the other. If carcinoma cannot be definitely excluded, the patient must be operated on promptly. At operation, the history, the barium enema study and the appearance of the lesion are carefully considered in making a tentative diagnosis for or against cancer. If the tentative diagnosis is diverticulitis and the inflammatory reaction is extensive, a transverse colostomy may be done. A barium enema study should then be repeated within two to three weeks and the question of the presence of carcinoma again considered. If it still cannot be excluded, resection must be performed. If the diagnosis is probable diverticulitis but resection is feasible, this is the procedure of choice. If a conservative resection is carried out in the belief that the lesion is inflammatory, the bowel should be opened before the abdomen is closed. The presence of carcinoma will be recognized immediately upon opening the bowel and a more radical resection then performed. If it is the surgeon's opinion, based on all of the factors involved, that the lesion in all likelihood is carcinoma, a radical resection should be the initial procedure. BLEEDING. In recent years serious bleeding has become a more frequent indication for surgery in diverticulitis. In many instances, however, bleeding will stop with conservative treatment and blood replacement. Surgical intervention is indicated only when bleeding is persistent and profuse. It should be remembered that serious bleeding may occur in patients who have diverticulosis with no clinical or x-ray evidence of
SURGICAL TREATMENT FOR DIVERTICULITIS
669
inflammatory reaction in the colon. If the process is localized to a segment of the colon, such as the sigmoid, this area is resected. When the bleeding is associated with diverticulosis which involves the entire colon, and if no visible or palpable evidence of an inflammatory reaction can be found, a transverse colostomy may be carried out. If rectal bleeding continues but there is no bleeding from the proximal colon, the bleeding can be controlled by resection of the distal colon and total colectomy is thus avoided. Bleeding in a patient with diverticulitis, particularly if it is persistent but not profuse, is always an indication to make sure that carcinoma has been ruled out.
TECHNIQUE
Colostomy
The colostomy should be established in the mid or proximal transverse colon (Fig. 1). This will permit easy mobilization of the splenic flexure should it be necessary at the subsequent resection. The incision is placed in the right upper quadrant so that the colostomy is well removed from the area of the second incision. It is important that the area of the perforation (or fistula) be completely defunctionalized. This means that feces should not pass over into the distal colon. The most effective way to do this is to divide the bowel completely at the time the colostomy is made. There is a tendency for the mobile transverse colon to prolapse unless the mesentery is securely fixed to the abdominal wall. The great omentum must, of course, be detached at the point where the bowel is exteriorized. The exteriorized colon may be supported by a glass or metal rod and divided later with the cautery. I prefer to divide it immediately between Ochsner clamps and to decompress the proximal limb by a catheter if significant dilatation is present. If a large abscess is present in the left lower quadrant, drainage by an extraperitoneal approach will hasten resolution of the abscess. Closure of Colostomy
Except in rare instances, the colostomy should not be closed before resection of the diseased bowel is carried out. Recurrence of symptoms and probably a recurrence of the complication (perforation or obstruction) are likely to occur. The length of time that should elapse before resection is carried out will vary according to the extent of the inflammatory reaction which was present at the time the colonic stoma was established. If the presence of carcinoma has been ruled out, the longer the inflammatory reaction is allowed to subside the easier will be the subsequent resection. The chance of serious postoperative complications after resection will also be reduced. As a general rule, if a large inflammatory mass is present at the time of colostomy, resection should be delayed for at least four months.
670
BENTLEY
P.
COLCOCK
Figure 1. A, A portion of the proximal transverse colon has been exteriorized and completely divided. The shaded area indicates the segment of colon involved with acute diverticulitis, often associated with a large pericolic abscess. B, After the fecal etream has been completely diverted for four to six months, the inflammatory process will subside, leaving a shrunken, scarred, but otherwise normal sigmoid colon. C, The diseased segment of colon has been removed. The ends can be approximated without tension due to mobilization of the splenic flexure. The circle above indicates the restoration of intestinal continuity by an end-to-end anastomosis as soon as the colorectal anastomosis has healed.
With encouragement and the use of a plastic colostomy appliance, most of these patients will return to work during this interval. If the inflammatory reaction has completely subsided at the time of resection, closure of the colostomy at the same operation may be considered. It should not be done, however, unless the surgeon is completely satisfied with the anastomosis. A small leak at the anastomosis will do no harm if a proximal colostomy is present. If the colostomy has been closed, a leak will lead to abscess formation, which will require incision and drainage and
SURGICAL TREATMENT FOR DIVERTICULITIS
671
a second colostomy. It is safer to close the colostomy two to three weeks after the resection. If considerable inflammatory reaction was present in the bowel wall at the time of the resection and anastomosis, closure of the colostomy should be delayed for one to two months. Under these circumstances it is well to do a barium enema study before closing the colostomy. The colostomy may be closed despite extravasation of a small amount of barium at the suture line. It is important, however, to be sure that stenosis of the anastomosis is not present.
Resection If a primary one-stage resection (Fig. 2) is planned, the bowel is prepared before operation. Colonic irrigations and the usual laxative are omitted because of the danger of perforation. Phthalylsulfathiazole (Sulfathalidine), 1 gm., and neomycin, 0.5 gm., are given every six hours for 36 to 48 hours. If a colostomy is already present, bowel preparation consists of irrigation of the distal segment of colon with the neomycin solution. A left paramedian incision is used, reflecting the left rectus muscle. The incision must frequently be long enough to permit mobilization of the splenic flexure and the construction of an anastomosis just above the symphysis pubis. The paramedian incision will permit preservation of the blood supply and nerve supply to the rectus muscle. A primary one-stage resection is hazardous unless all of the inflamed colon is removed. Leakage is also likely to occur if the anastomosis is made through a segment con-
A
Figure 2. A, The posterior walls of the proximal and of the distal segments have been approximated with interrupted sutures of silk. B, The mucosal and submucosal layers of the posterior wall are united with interrupted sutures of silk or fine catgut. The anterior wall of the colon and rectum is sutured in a similar manner.
6-72
BENTLEY
P.
COLCOCK
Figure 3. Primary resection for diverticulitis. The acutely inflamed segment of colon is dissected free of its attachments and resected. Sufficient bowel should be resected on both sides of the lesion so that normal colon can be approximated to normal rectum, as shown on the right. Whether or not the splenic flexure will need to be mobilized will depend upon the extent of the inflammatory process. There must be no tension upon the suture line.
taining many diverticula. The two ends must be brought together without tension. Anyone or more of these factors will determine the need for mobilization of the splenic flexure. Suction apparatus should be available in case a small abscess is encountered as the colon is mobilized. The left ureter is likely to be adherent to the posterior surface of the involved sigmoid. Diverticulitis does not involve the rectum except secondarily. Unless it has been damaged by previous inflammation or previous surgery, normal rectum will be found to form the distal part of the anastomosis. The superior hemorrhoidal artery and vein are preserved unless carcinoma has not been excluded. It is always well to have the resected bowel opened as soon as it has been removed, even when the process is thought to be entirely inflammatory. Carcinoma of the sigmoid can be recognized immediately upon opening the bowel and a more radical resection of the mesentery carried out. The anastomosis may be made by anyone of several methods. I prefer an end-to-end anastomosis using only interrupted sutures so as to
SURGICAL TREATMENT FOR DIVERTICULITIS
673
obtain as large a lumen as possible (Fig. 3). The descending colon will usually cover the denuded left lumbar gutter, and reperitonealization is rarely necessary. This is particularly true if the splenic flexure has been mobilized. If the surgeon is concerned for any reason about the integrity of the anastomosis, he should protect it with a proximal transverse colostomy. It cannot be emphasized too strongly that a cecostomy is not adequate to protect an insecure anastomosis of the distal colon. A proximal colostomy is not used routinely.
SUMMARY
Deaths still occur from peritonitis secondary to a perforated diverticulum of the colon. Death may occur within 24 hours of the onset of symptoms. Patients with acute diverticulitis need intensive supportive treatment, fluids, electrolytes, and antibiotics. These, however, are not adequate substitutes for a prompt diversion of the fecal stream by transverse colostomy if signs of peritonitis are present. Serious complications and even a fatality may occur as the result of carrying out a resection in the presence of acute inflammation. With careful selection of cases for primary resection and meticulous technique with both the multiple and the single stage procedures, the mortality and morbidity rates for the surgical treatment of diverticulitis can be kept at a very low figure.