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The Management of Complicated Diverticulitis
Advances in Surgery 40 (2006) 285–297
ADVANCES IN SURGERY The Management of Complicated Diverticulitis Jennifer R. Chapman, MDa,b,*, Bruce G. Wolff, MDb a
Franciscan Skemp Hospital, 800 West Avenue South, La Crosse, WI 54601, USA Department of Surgery, Division of Colorectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
b
COMPLICATED DIVERTICULITIS Colonic diverticulosis is among the most common diseases of developed western countries. Although most people who have diverticular disease remain asymptomatic, 10% to 25% of patients who have diverticulosis ultimately progress to diverticulitis. Of those patients who develop diverticulitis, 15% develop significant complications [1–3]. Diverticulitis by definition implies inflammation at the site of the diverticulum. If a microperforation occurs, an intense inflammatory reaction of the colon wall and the surrounding mesentery and soft tissues may develop [4,5]. This inflammatory process may remain confined or it may progress to form an abscess, which can be walled off by adjacent structures, perforate freely into the peritoneal cavity, or fistulize into an adjacent organ. Obstruction can result from bowel wall spasm, abscess, or inflammatory reaction. Healing of the inflammation may lead to stricture development. Free perforation with subsequent diffuse peritonitis may result from the initial inflamed diverticulum. Complicated diverticular disease is thus defined as diverticulitis with associated abscess, phlegmon, fistula, bleeding, or perforation [1–11] (Fig. 1). The patient who has complicated diverticulitis may present at any point on this clinical spectrum [4–6]. In a comprehensive report by Rodkey and Welch, the relative frequency of various complications of diverticulitis was 10.9% with pericolic abscess, 32.3% with perforation with local peritonitis or pelvic abscess, 14.6% with generalized peritonitis, 10.9% with obstruction, 8.2% with bleeding, and 9.7% with fistula [7]. In a more recent review of patients who presented with complicated diverticulitis, 22.3% of patients suffered from acute phlegmon, 29.5% had a paracolic abscess, 22.6% had an obstruction or stricture, 13.4% were found to have a fistula, 4.5% had bleeding associated with their diverticulitis, and 44% presented with a contained or free perforation [8]. *Corresponding author. E-mail address: [email protected] (J.R. Chapman). 0065-3411/06/$ – see front matter doi:10.1016/j.yasu.2006.06.006
ª 2006 Elsevier Inc. All rights reserved.
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Fig. 1. Major complications of diverticular disease of the sigmoid colon. Used with permission from Zollinger RW, Zollinger RM. Diverticular disease of the colon. Adv Surg 1971;5:255.
CLINICAL PRESENTATION AND EXAMINATION Patients may present with symptoms compatible with uncomplicated diverticulitis or they may present in severe sepsis because of the broad clinical spectrum of complicated diverticular disease. Most patients present with abdominal pain, usually localized to the left lower quadrant. Variable degrees of guarding and rebound tenderness are found on examination. In a recent review of patients who were admitted for complicated diverticulitis, 76% had normal vital signs at presentation and fever was seen in only 22.8% of the patients [8]. Leukocytosis is common, with the average white blood cell count being 11.2 6.0. In patients who have a pericolic abscess or phlegmon, a mass is occasionally palpated on abdominal, rectal, or pelvic examination. In a patient who has a colovaginal fistula, a site of granulation tissue and drainage is seen at the apex of the vaginal cuff [12]. Pneumaturia, fecaluria, and urinary urgency and dysuria are frequent complaints of patients who have colovesical fistulas. A patient who has obstruction or stricture may present with marked abdominal distention, usually of slow onset. Patients who have free perforation most commonly
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complain of sudden abdominal tenderness that spreads throughout the abdomen. Depending on the patients’ comorbidities, the presentation may range from localized abdominal pain and tenderness to fevers, distention, hypotension, and hypovolemia. DIAGNOSIS An accurate diagnosis is essential to delineate the appropriate management for patients who have complicated diverticular disease. Assessment is made with clinical evaluation and frequent re-evaluation of the patient. This evaluation includes a thorough history and physical examination, frequent recording of pulse and temperature, serial blood counts, and radiographic imaging. Flat and upright abdominal radiographs are helpful in excluding free air in patients who present with abdominal pain and tenderness. The most useful diagnostic imaging study for complicated diverticulitis is an abdominal–pelvic CT scan [13]. In the acute setting, CT scans with oral, intravenous, and rectal contrast may detect a diverticular abscess or fistula, contained or free perforation, and obstruction caused by ileus or an inflammatory phlegmon. If symptoms persist in a patient who has uncomplicated diverticulitis, a repeat CT scan should be performed to rule out a subsequent complication. There is also emerging evidence that management of acute complicated diverticulitis can be based on severity of disease found on CT scanning [14,15]. DIVERTICULITIS ASSOCIATED WITH ABSCESS OR PHLEGMON A pericolic abscess or phlegmon can be localized in the mesentery or spread to the abdomen, the pelvis, the retroperitoneum, the buttocks, scrotum, or thighs. Patients who have this complication may present in a manner similar to uncomplicated diverticulitis. If fever, leukocytosis, abdominal pain, and tenderness persist despite antibiotic therapy, the presence of an abscess should be suspected. The presence or development of a tender palpable mass on abdominal or pelvic–rectal examination may also indicate an abscess or phlegmon. Diverticular abscesses have often been described by a classification system developed in 1978 by Hinchey and colleagues. The Hinchey classification was initially created to define diverticulitis associated with perforation [16] (Fig. 2). Patients who have Hinchey stage I were defined as having diverticulitis with a confined paracolic abscess; stage II was diverticulitis with distant (pelvic, retroperitoneal) abscess; stage III was diverticulitis with purulent peritonitis; and stage IV was diverticulitis with fecal peritonitis. Depending on the Hinchey stage, different management options and outcomes could be expected. A modification of Hinchey’s classification offered by Sher and colleagues stratified the stages further. In their classification, stage I is a small pericolic abscess; stage IIA is an intra-abdominal abscess amenable to percutaneous drainage; stage IIB is a complex intra-abdominal abscess associated with a fistula; and stage III and IV are unchanged from the original Hinchey classification [17]. Helical abdominal–pelvic CT scan with oral and intravenous contrast is the most accurate diagnostic evaluation for an abscess or phlegmon. In addition,
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Fig. 2. Hinchey classification. Used with permission from Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910–7.
the use of rectal contrast may identify a fistula associated with the abscess. Small (less than 4 cm) pericolic abscesses may be treated with bowel rest and broad spectrum intravenous antibiotics. Most of these smaller abscesses resolve without further intervention. Larger Hinchey stage II abscesses and stage I pericolic abscesses that do not respond to antibiotic therapy should be percutaneously drained. Radiologically-guided percutaneous drainage is the preferred choice for the treatment of large diverticular abscesses, with success rates of up to 90% [18]. Successful percutaneous drainage often leads to resolution of sepsis and improvement in symptoms and signs usually within 72 hours. It thereby facilitates subsequent elective surgical resection. Stabile and colleagues
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reported that percutaneous drainage of an abscess was successful in allowing a later, more elective single-stage resection and anastomosis of the colon to be done in 74% of their patients [19]. In a recent Mayo Clinic review, 25 of 27 patients who underwent percutaneous drainage had resolution of their symptoms and underwent elective one-stage sigmoid resection without difficulty [8] (Fig. 3). Accessing a large pelvic or retroperitoneal abscess may be difficult, and the drainage procedure typically must be done with the patient in a prone or lateral position. If the catheter drainage amounts to more than 500 mL per day after the first 24 hours, a fistula should be suspected [12]. Before removing the drain, an abscess cavity check should be done. A CT scan or sinogram is performed with injection of contrast material through the tube to determine whether the cavity has collapsed. If a diverticular abscess develops after the drain is removed, percutaneous drainage can be reattempted. The drain, however, should be left in place until elective surgery if there is a persistent large cavity or redevelopment of an abscess. The optimal time to wait before elective resection has not been determined, but most surgeons wait 4 to 6 weeks to allow for resolution of the inflammatory process. Failure of clinical improvement with percutaneous drainage is most often seen in patients who have multiple or multiloculated abscesses. Moreover, percutaneous drainage is not typically used in the treatment of immunocompromised patients because of their high risk for deterioration and failure. If
Fig. 3. Diverticular abscess. (A) Diagnostic CT. (B) Percutaneous drain placed. (C) Intraoperative resection of bowel with percutaneous drain in place.
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percutaneous drainage is unable to be performed or is unsuccessful in draining the abscess adequately, if the phlegmon worsens with ensuing obstruction, or if the patient’s clinical condition deteriorates, an expeditious operation may be necessary [3,6,10,12]. DIVERTICULITIS ASSOCIATED WITH PERFORATION Patients who have Hinchey stage III and IV disease often present in a manner similar to that of patients who have a perforated viscus from any other etiology. Patients demonstrate peritoneal signs on physical examination and systemic signs of sepsis. Immunocompromised patients, however, may not mount the same abdominal pain, peritonitis, leukocytosis, and systemic signs, leading to delay in diagnosis and management. High clinical suspicion is warranted in these patients. Preoperative work-up should be minimized when peritonitis is identified. Radiologic studies may reveal free air and fluid in the peritoneal cavity. Once peritonitis is identified, urgent operative exploration of the patient is mandated. Before surgical exploration the patient should receive appropriate initial resuscitation with fluid volume and the administration of broad-spectrum intravenous antibiotics. Abdominal wall marking for ileostomy or colostomy should also be done. In the operating room, invasive monitoring and large-bore intravenous lines are placed as indicated, and the patient is positioned in the modified dorsal lithotomy position. An upper-body, forced hot-air warmer should be used, and if the patient is not febrile the operating room should be warmed. Ureteral stents placed at cystoscopy in the operating room just before laparotomy should be considered to facilitate identification of the ureters and avoid injury. A gentle proctoscopic examination should also be performed before incision to empty the rectum and to confirm that no other disease is present. A generous midline incision is used to permit adequate visualization of all viscera. Although reports of laparoscopic exploration and resection have been published, these cases have been done in select patients, and this technique is not routinely advised [20,21]. Exploration is performed to confirm the diagnosis, determine the extent of contamination, and exclude other pathology. As many as 25% of patients who have a preoperative diagnosis of complicated diverticulitis are found to have a perforated carcinoma [22]. Intra-abdominal contamination should be washed out, and if the open colonic perforation is still leaking, it should be contained with primary closure or clamp. Colon resection should be attempted in all cases. Patients who have complications of diverticular disease are almost always best managed by not only draining any abscess and controlling peritonitis but also resecting the inflamed segment. Management with a three-stage procedure is outdated and not recommended. Finlay and Carter reported greater morbidity in patients treated with colostomy and drainage [23]. In one study from the Mayo Clinic there was a significantly higher mortality in patients treated with a colostomy and drainage (26%) versus those treated with resection (7%) [24]. The increased mortality and morbidity rates in patients who underwent three-stage operations were confirmed in other studies also [7,25,26].
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Hartmann’s procedure (resection with oversewn rectal stump and end ostomy) is the operation of choice for patients who have purulent or feculent peritonitis. Primary anastomosis is not advised in the setting of gross purulent or fecal peritonitis. After closure of the fascia, consideration should be given to allow the skin wound to heal by secondary intention or loosely reapproximate the skin edges to decrease the risk for wound infection. Mortality rates from perforated diverticulitis with fecal peritonitis have been reported to range from 12.6% to 39% [6,8,24]. Preoperative medical comorbidity and delay in appropriate surgical intervention can greatly affect these rates. As many as 30% of patients remain with a permanent colostomy after the Hartmann’s procedure, whereas those who undergo colostomy closure have a major complication rate ranging from 4% to 10% [18]. DIVERTICULITIS ASSOCIATED WITH FISTULA Most patients who have fistula formation secondary to diverticular disease do not present with acute intra-abdominal sepsis but instead develop signs and symptoms of the fistula following one or more episodes of diverticulitis. In some patients a diverticular fistula develops without a clear history of diverticulitis [18]. The most common diverticular fistulas are colovesical, which account for 68% of patients [27]. Colovesical fistulas are more common in men than in women (2:1) because the uterus serves as a barrier to separate the sigmoid colon from other hollow viscera in women. Most women who develop diverticular colovesical or colovaginal fistula have undergone a prior hysterectomy. Symptoms of colovesical fistula are primarily urologic, including cystitis (90%), pneumaturia (75%), and fecaluria (50%). Abdominal pain, hematuria, fevers, and chills can also be seen. Colovaginal fistulas are the second most common type of diverticular fistula, accounting for 25% of such cases [6]. Patients most commonly complain of vaginal discharge (90%) but may also have passage of air or stool through their vagina. Less common diverticular fistulas include coloenteric, colouterine, and colocutaneous. The entire colon should be evaluated preoperatively by colonoscopy or contrast enema to exclude cancer and inflammatory bowel disease. The diagnosis of a colovesical fistula is best confirmed by a CT scan, which establishes the diagnosis in more than 90% of patients [28]. The classic findings are sigmoid diverticula, thickening of the bladder and the colon, air in the bladder, and opacification of the fistula tract and the bladder (Fig. 4). Cystoscopy identifies the site of fistulas in approximately 90% of patients by showing a focal area of inflammation. Visualization of the fistula on cystoscopy allows for a better understanding of the location of the fistula in relation to the ureters. The location of the fistula may indicate a possible need for ureteral catheterization before operation. The diagnostic tests most useful for detecting colovaginal fistulas are a CT scan and vaginoscopy/vaginal examination, which show thickening of the vaginal cuff, air within the vagina, a focal area of granulation or erythema, and purulent or feculent drainage. Initial management includes treatment of any acute inflammation or urosepsis with appropriate antibiotics. If a patient is found to have a fistula in the
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Fig. 4. CT scan (anterior, posterior, and coronal views) showing colovesical fistula.
setting of acute diverticulitis, treatment of the diverticulitis is undertaken with intravenous antibiotics and bowel rest. Further diagnostic evaluation or treatment is deferred for 4 to 6 weeks to allow for the inflammation to resolve. A full bowel preparation is given, and the patient is placed in the Lloyd-Davies position. Ureteral stents should be considered in any patient who has a fistula located low on the bladder or near the ureteral orifices, or in a patient who has persistent inflammatory changes. A laparotomy or laparoscopy is performed to resect the involved segment of bowel with primary anastomosis. If available, omentum or other healthy, well-vascularized tissue should be placed between the anastomosis and the previously contiguous organ. The bladder site of the fistula does not require bladder resection, but only simple oversewing and Foley catheter drainage for approximately 7 to 10 days. A cystogram is typically performed before removing the catheter. The same procedure is applied for patients who have colovaginal fistula. Vaginal defects, if identified, are repaired by excising involved tissue and oversewing. DIVERTICULITIS ASSOCIATED WITH OBSTRUCTION Diverticulitis-associated stricture or large bowel obstruction usually presents in two forms: (1) acute or (2) delayed as a consequence of fibrosis. Colonic obstruction in the setting of acute diverticulitis is usually partial. Diagnosis is made by physical examination and radiographic studies. Plain abdominal radiographs and CT scan are the most useful tools in determination of diverticulitis associated with obstruction. These studies help to differentiate small bowel obstruction that may occur as a consequence of adherence of the small bowel to a focus of diverticulitis, ileus from the inflammation, or a large bowel obstruction caused by an abscess, inflammatory phlegmon, or acute stricture (Fig. 5). Prompt hydration, intravenous antibiotics, and nasogastric decompression generally lead to improvement and allow for bowel preparation. A gentle watersoluble contrast enema can help confirm the diagnosis, exclude an obstructing sigmoid carcinoma, and provide a cathartic effect to help decompress the colon [6]. Slow oral bowel preparation, gentle irrigation enemas, or both can
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Fig. 5. Patient with large bowel obstruction from diverticulitis stricture. Used with permission from Welch JP, Cohen JL. Diverticulitis. In: Souba WW, editor. ACS surgery: principles and practice. 2004. p. 1–14.
be attempted, but this procedure should be stopped immediately if recurrent symptoms develop. Frequent abdominal examinations and abdominal radiographs should be done if attempting to decompress and prepare the bowel in an obstructed patient. In a recent analysis of the management of complicated diverticulitis, large bowel obstruction was treated by resection and anastomosis in 70% of patients [8]. High-grade obstruction represents a complex problem. If the cecum is dilated to a diameter of 10 cm or greater and there is tenderness in the right lower quadrant as a result of the obstruction, expeditious surgery is necessary because of the risk for cecal necrosis and perforation. High-grade obstruction with fecal loading of the colon is usually managed by performing a Hartmann procedure, though on-table lavage with resection and primary anastomosis with or without a diverting loop ileostomy may be considered [6,10,12]. To consider a one-stage approach, conditions should be made optimal before a primary anastomosis is performed. The patient should have a low-risk preoperative health status and be hemodynamically stable before and during the operation. The bowel must have a good blood supply, healthy resection margins, lack of tension, and lack of surrounding inflammation. Relative contraindications to primary anastomosis include high-risk patients (severe medical problems, poor nutrition, high-dose steroids or immunocompromised, history of local radiation), presence of edematous bowel with questionable viability, poor blood supply, hemodynamically unstable, and presence of purulent or feculent peritonitis.
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In those patients in whom a preoperative mechanical bowel preparation was not possible and the proximal colon is loaded with feces, but when other conditions favor an anastomosis, on-table lavage may be performed. Mortality rates range from 1% to 7% and anastomotic leak rates range from 1% to 4% in patients who have undergone on-table lavage followed by primary anastomosis [8,12,18]. This technique adds approximately 30 to 45 minutes to the operation. On-table lavage requires mobilization of both flexures of the colon. A large, soft catheter is introduced by way of an appendicostomy or through a distal ileal enterotomy surrounded by a pursestring. The colon is intubated at the proximal resection margin with a long piece of sterile corrugated anesthesia tubing, which is passed off the operating table so the effluent can be collected. Several liters of saline are infused by way of the proximal catheter. A noncrushing bowel clamp is placed on the distal ileum proximal to the infusing catheter to prevent fluid from moving retrograde. When the lavage returns are clear, 50 mL of Betadine are added to the final 500 mL of saline infusate. After completion of the lavage, the catheter and tubing are removed and the appendectomy completed or the ileotomy repaired [29] (Fig. 6). The rectal stump can be lavaged until clear with proctoscopy. A primary anastomosis can then be performed in a routine manner. A dedicated preformed kit that is easily accessible in the operating room is necessary to perform the on-table lavage maneuver appropriately. The need for on-table lavage is controversial. Recent studies indicate no significant difference in morbidity or anastomotic leak in patients who do not receive a mechanical bowel preparation before elective sigmoid resection [30,31]. In patients who are at low risk from a health standpoint and with minimal fecal spillage, no hemodynamic instability, and healthy tissue at the margins of resection, another surgical option for treatment would be a primary anastomosis with a proximal covering stoma. The diverting stoma is closed in 8 to 12 weeks after contrast studies confirm healing. There have also been cases reported of patients undergoing successful resection and primary anastomosis in patients who have complicated diverticular disease without bowel preparation. Patients who present with a fibrotic stricture after recovery from diverticulitis usually display symptoms of a partial obstruction. Patients complain of persistent diarrhea, crampy abdominal pain, and bloating. Diagnosis is aided by CT scan, barium enema, and sigmoidoscopy. Patients are given gentle bowel preparation and proceed with a laparoscopic or open resection and primary anastomosis. DIVERTICULITIS ASSOCIATED WITH BLEEDING Lower gastrointestinal bleeding associated with acute diverticulitis is an uncommon manifestation occurring in 4% to 8.2% of patients [8,26]. Attempts are made to establish the active bleeding site by means of tagged red blood cell nuclear scans or angiography. Endoscopy may be used in select patients who have little inflammation, but is usually contraindicated in the setting of acute diverticulitis. Emergency resection is indicated if the bleeding is life-threatening and if colonic angiography and attempted embolization is unsuccessful.
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Fig. 6. On-table lavage. (A) On-table lavage diagram. (B) Intra-operative picture of on-table lavage. (C ) Full view of intra-operative on-table lavage.
GUIDELINES
In the American Society of Colon and Rectal Surgeons Practice Parameters for the Treatment of Sigmoid Diverticulitis published in 2000, sigmoid resection was recommended after one episode of complicated diverticulitis [9]. CT scan is the most useful diagnostic tool in the evaluation of complicated diverticulitis. Patients who present with obstruction, abscess, or a colovesical fistula, and diverticula may have a malignancy as the cause of their inflammation and symptoms. If there is the slightest doubt of the cause of the disease at the time of operative exploration, the assumption that a possible malignancy is present must be made and a concomitant en bloc resection of any contiguous organs or tissue should be performed.
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Percutaneous drainage of large abscesses should be considered to improve symptoms and allow for elective one-stage resection. Relative contraindications to percutaneous drainage include small abscesses, immunocompromised patients, multiloculated abscesses, and clinical deterioration. Resection and immediate anastomosis are suitable for patients who have Hinchey stage I and II diverticular abscesses/phlegmons, whereas resection with diversion (the Hartmann procedure) is the gold standard for patients who have purulent or feculent peritonitis. Three-stage procedures are associated with increased morbidity and mortality and are of historic interest only. Resect colon and fistula in one-stage procedure with simple repair of the fistula site on the contiguous organ. High-grade obstructions should be treated surgically. If select conditions present, consider one-stage procedure with or without on-table lavage. In high-risk patients, setting of inflammation, or poor conditions, the Hartmann procedure is recommended. Partial obstruction should be treated medically, followed by gentle and slow bowel preparation to allow one-stage procedure. Laparoscopic approach can be used for the treatment of Hinchey stage I and II abscess, phlegmon, or decompressed colon obstruction from stricture without significant difference compared to open. The more inflammation present at the time of the operation, however, the higher the conversion rate [17].
References [1] Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4: 53–69. [2] Waugh JM, Walt AJ. Current trends in the surgical treatment of diverticulitis of the sigmoid colon. Surg Clin N Am 1962;43:1267–76. [3] Aydin HN, Remzi FH. Diverticulitis: when and how to operate? Dig Liver Dis 2004;36: 435–45. [4] Chappius CW, Cohn I Jr. Acute colonic diverticulitis. Surg Clin N Am 1988;68:301–13. [5] Rege RV, Nahrwold DL. Diverticular disease. Curr Prob Surg 1989;26:133–89. [6] Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin N Am 1993;73:975–92. [7] Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984;200:466–78. [8] Chapman JR, Davies MM, Wolff BG, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005;243(6):876–80. [9] Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis—supporting documentation. Dis Colon Rectum 2000;43:289–97. [10] Schwesinger WH, Page CP, Gaskill HV, et al. Operative management of diverticular emergencies: strategies and outcomes. Arch Surg 2000;135:558–62. [11] Zollinger RW, Zollinger RM. Diverticular disease of the colon. Adv Surg 1971;5:255. [12] Welch JP, Cohen JL. Diverticulitis. In: Souba WW, editor. ACS surgery: principles and practice. New York: Web MD Professional Pub; 2004. p. 1–14. [13] Labs JD, Sarr MG, Fishman EK, et al. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155: 331–6. [14] Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910–7. [15] Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on surgical management—a prospective study of 542 patients. Eur Radiol 2002;12:1145–9.
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[16] Hinchey GC, Schall GH, Richards MB. Treatment of perforated diverticulitis of the colon. Adv Surg 1978;12:85. [17] Sher ME, Agachan F, Bortul M, et al. Laparoscopic surgery for diverticulitis. Surg Endosc 1997;11:264–7. [18] Kaufmann HS, Sonnenday CJ. Diverticulitis. In: Bland KI, editor. The practice of general surgery. Philadelphia: W.B. Saunders Company; 2002. p. 503–8. [19] Stabile BE, Puccio E, Van Sonnenberg E, et al. Preoperative percutaneous drainage of diverticular abscess. Am J Surg 1990;159:99–104. [20] Scheidbach H, Schneider S, Rose J, et al. Laparoscopic approach to treatment of sigmoid diverticulitis: changes in the spectrum of indications and results of a prospective, multicenter study on 1,545 patients. 2004;47(11):1883–8. [21] Kockerling F, Schneider C, Reymond MA, et al. Laparoscopic resection of sigmoid diverticulitis results of a multicenter study Laparoscopic Colorectal Surgery Study Group. Surg Endosc 1999;13:567–71. [22] Colcock BP. Surgical management of complicated diverticulitis. N Engl J Med 1958;259: 570–3. [23] Finlay IG, Carter DC. A comparison of emergency resection and staged management in perforated diverticular disease. Dis Colon Rectum 1987;30:929–33. [24] Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985;28:71–5. [25] Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71:921–7. [26] Hackford AW, Schoetz DJ, Coller JA, et al. Surgical management of complicated diverticulitis: the Lahey Clinic experience, 1967 to 1982. Dis Colon Rectum 1985;28:317–21. [27] Pontari MA, McMillen MA, Garvey RH, et al. Diagnosis and treatment of enterovesical fistulae. Am Surg 1992;58:258–63. [28] Goldman SM, Fishman EK, Gatewood OM, et al. CT in diagnosis of enterovesical fistulae. Am J Roentgenol 1985;144:1229–33. [29] Gordon PH. Malignant neoplasms of the colon. In: Gordon PH, Nivatvongs S, editors. Principles and practices of surgery for the colon, rectum, and anus. 2nd edition. St. Louis: Quality Medical Publishing; 1999. [30] Goldstone AR, Kennedy N, Metcalfe M. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92:409–14. [31] Fa-Sie-Oen P, Rounen R, Buitenweg J, et al. Mechanical bowel prep or not? Outcome of a multicenter, randomized trial in elective colon surgery. Dis Colon Rectum 2005;48: 1509–16.
ADVANCES IN SURGERY The Management of Complicated Diverticulitis Jennifer R. Chapman, MDa,b,*, Bruce G. Wolff, MDb a
Franciscan Skemp Hospital, 800 West Avenue South, La Crosse, WI 54601, USA Department of Surgery, Division of Colorectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
b
COMPLICATED DIVERTICULITIS Colonic diverticulosis is among the most common diseases of developed western countries. Although most people who have diverticular disease remain asymptomatic, 10% to 25% of patients who have diverticulosis ultimately progress to diverticulitis. Of those patients who develop diverticulitis, 15% develop significant complications [1–3]. Diverticulitis by definition implies inflammation at the site of the diverticulum. If a microperforation occurs, an intense inflammatory reaction of the colon wall and the surrounding mesentery and soft tissues may develop [4,5]. This inflammatory process may remain confined or it may progress to form an abscess, which can be walled off by adjacent structures, perforate freely into the peritoneal cavity, or fistulize into an adjacent organ. Obstruction can result from bowel wall spasm, abscess, or inflammatory reaction. Healing of the inflammation may lead to stricture development. Free perforation with subsequent diffuse peritonitis may result from the initial inflamed diverticulum. Complicated diverticular disease is thus defined as diverticulitis with associated abscess, phlegmon, fistula, bleeding, or perforation [1–11] (Fig. 1). The patient who has complicated diverticulitis may present at any point on this clinical spectrum [4–6]. In a comprehensive report by Rodkey and Welch, the relative frequency of various complications of diverticulitis was 10.9% with pericolic abscess, 32.3% with perforation with local peritonitis or pelvic abscess, 14.6% with generalized peritonitis, 10.9% with obstruction, 8.2% with bleeding, and 9.7% with fistula [7]. In a more recent review of patients who presented with complicated diverticulitis, 22.3% of patients suffered from acute phlegmon, 29.5% had a paracolic abscess, 22.6% had an obstruction or stricture, 13.4% were found to have a fistula, 4.5% had bleeding associated with their diverticulitis, and 44% presented with a contained or free perforation [8]. *Corresponding author. E-mail address: [email protected] (J.R. Chapman). 0065-3411/06/$ – see front matter doi:10.1016/j.yasu.2006.06.006
ª 2006 Elsevier Inc. All rights reserved.
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Fig. 1. Major complications of diverticular disease of the sigmoid colon. Used with permission from Zollinger RW, Zollinger RM. Diverticular disease of the colon. Adv Surg 1971;5:255.
CLINICAL PRESENTATION AND EXAMINATION Patients may present with symptoms compatible with uncomplicated diverticulitis or they may present in severe sepsis because of the broad clinical spectrum of complicated diverticular disease. Most patients present with abdominal pain, usually localized to the left lower quadrant. Variable degrees of guarding and rebound tenderness are found on examination. In a recent review of patients who were admitted for complicated diverticulitis, 76% had normal vital signs at presentation and fever was seen in only 22.8% of the patients [8]. Leukocytosis is common, with the average white blood cell count being 11.2 6.0. In patients who have a pericolic abscess or phlegmon, a mass is occasionally palpated on abdominal, rectal, or pelvic examination. In a patient who has a colovaginal fistula, a site of granulation tissue and drainage is seen at the apex of the vaginal cuff [12]. Pneumaturia, fecaluria, and urinary urgency and dysuria are frequent complaints of patients who have colovesical fistulas. A patient who has obstruction or stricture may present with marked abdominal distention, usually of slow onset. Patients who have free perforation most commonly
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complain of sudden abdominal tenderness that spreads throughout the abdomen. Depending on the patients’ comorbidities, the presentation may range from localized abdominal pain and tenderness to fevers, distention, hypotension, and hypovolemia. DIAGNOSIS An accurate diagnosis is essential to delineate the appropriate management for patients who have complicated diverticular disease. Assessment is made with clinical evaluation and frequent re-evaluation of the patient. This evaluation includes a thorough history and physical examination, frequent recording of pulse and temperature, serial blood counts, and radiographic imaging. Flat and upright abdominal radiographs are helpful in excluding free air in patients who present with abdominal pain and tenderness. The most useful diagnostic imaging study for complicated diverticulitis is an abdominal–pelvic CT scan [13]. In the acute setting, CT scans with oral, intravenous, and rectal contrast may detect a diverticular abscess or fistula, contained or free perforation, and obstruction caused by ileus or an inflammatory phlegmon. If symptoms persist in a patient who has uncomplicated diverticulitis, a repeat CT scan should be performed to rule out a subsequent complication. There is also emerging evidence that management of acute complicated diverticulitis can be based on severity of disease found on CT scanning [14,15]. DIVERTICULITIS ASSOCIATED WITH ABSCESS OR PHLEGMON A pericolic abscess or phlegmon can be localized in the mesentery or spread to the abdomen, the pelvis, the retroperitoneum, the buttocks, scrotum, or thighs. Patients who have this complication may present in a manner similar to uncomplicated diverticulitis. If fever, leukocytosis, abdominal pain, and tenderness persist despite antibiotic therapy, the presence of an abscess should be suspected. The presence or development of a tender palpable mass on abdominal or pelvic–rectal examination may also indicate an abscess or phlegmon. Diverticular abscesses have often been described by a classification system developed in 1978 by Hinchey and colleagues. The Hinchey classification was initially created to define diverticulitis associated with perforation [16] (Fig. 2). Patients who have Hinchey stage I were defined as having diverticulitis with a confined paracolic abscess; stage II was diverticulitis with distant (pelvic, retroperitoneal) abscess; stage III was diverticulitis with purulent peritonitis; and stage IV was diverticulitis with fecal peritonitis. Depending on the Hinchey stage, different management options and outcomes could be expected. A modification of Hinchey’s classification offered by Sher and colleagues stratified the stages further. In their classification, stage I is a small pericolic abscess; stage IIA is an intra-abdominal abscess amenable to percutaneous drainage; stage IIB is a complex intra-abdominal abscess associated with a fistula; and stage III and IV are unchanged from the original Hinchey classification [17]. Helical abdominal–pelvic CT scan with oral and intravenous contrast is the most accurate diagnostic evaluation for an abscess or phlegmon. In addition,
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Fig. 2. Hinchey classification. Used with permission from Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910–7.
the use of rectal contrast may identify a fistula associated with the abscess. Small (less than 4 cm) pericolic abscesses may be treated with bowel rest and broad spectrum intravenous antibiotics. Most of these smaller abscesses resolve without further intervention. Larger Hinchey stage II abscesses and stage I pericolic abscesses that do not respond to antibiotic therapy should be percutaneously drained. Radiologically-guided percutaneous drainage is the preferred choice for the treatment of large diverticular abscesses, with success rates of up to 90% [18]. Successful percutaneous drainage often leads to resolution of sepsis and improvement in symptoms and signs usually within 72 hours. It thereby facilitates subsequent elective surgical resection. Stabile and colleagues
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reported that percutaneous drainage of an abscess was successful in allowing a later, more elective single-stage resection and anastomosis of the colon to be done in 74% of their patients [19]. In a recent Mayo Clinic review, 25 of 27 patients who underwent percutaneous drainage had resolution of their symptoms and underwent elective one-stage sigmoid resection without difficulty [8] (Fig. 3). Accessing a large pelvic or retroperitoneal abscess may be difficult, and the drainage procedure typically must be done with the patient in a prone or lateral position. If the catheter drainage amounts to more than 500 mL per day after the first 24 hours, a fistula should be suspected [12]. Before removing the drain, an abscess cavity check should be done. A CT scan or sinogram is performed with injection of contrast material through the tube to determine whether the cavity has collapsed. If a diverticular abscess develops after the drain is removed, percutaneous drainage can be reattempted. The drain, however, should be left in place until elective surgery if there is a persistent large cavity or redevelopment of an abscess. The optimal time to wait before elective resection has not been determined, but most surgeons wait 4 to 6 weeks to allow for resolution of the inflammatory process. Failure of clinical improvement with percutaneous drainage is most often seen in patients who have multiple or multiloculated abscesses. Moreover, percutaneous drainage is not typically used in the treatment of immunocompromised patients because of their high risk for deterioration and failure. If
Fig. 3. Diverticular abscess. (A) Diagnostic CT. (B) Percutaneous drain placed. (C) Intraoperative resection of bowel with percutaneous drain in place.
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percutaneous drainage is unable to be performed or is unsuccessful in draining the abscess adequately, if the phlegmon worsens with ensuing obstruction, or if the patient’s clinical condition deteriorates, an expeditious operation may be necessary [3,6,10,12]. DIVERTICULITIS ASSOCIATED WITH PERFORATION Patients who have Hinchey stage III and IV disease often present in a manner similar to that of patients who have a perforated viscus from any other etiology. Patients demonstrate peritoneal signs on physical examination and systemic signs of sepsis. Immunocompromised patients, however, may not mount the same abdominal pain, peritonitis, leukocytosis, and systemic signs, leading to delay in diagnosis and management. High clinical suspicion is warranted in these patients. Preoperative work-up should be minimized when peritonitis is identified. Radiologic studies may reveal free air and fluid in the peritoneal cavity. Once peritonitis is identified, urgent operative exploration of the patient is mandated. Before surgical exploration the patient should receive appropriate initial resuscitation with fluid volume and the administration of broad-spectrum intravenous antibiotics. Abdominal wall marking for ileostomy or colostomy should also be done. In the operating room, invasive monitoring and large-bore intravenous lines are placed as indicated, and the patient is positioned in the modified dorsal lithotomy position. An upper-body, forced hot-air warmer should be used, and if the patient is not febrile the operating room should be warmed. Ureteral stents placed at cystoscopy in the operating room just before laparotomy should be considered to facilitate identification of the ureters and avoid injury. A gentle proctoscopic examination should also be performed before incision to empty the rectum and to confirm that no other disease is present. A generous midline incision is used to permit adequate visualization of all viscera. Although reports of laparoscopic exploration and resection have been published, these cases have been done in select patients, and this technique is not routinely advised [20,21]. Exploration is performed to confirm the diagnosis, determine the extent of contamination, and exclude other pathology. As many as 25% of patients who have a preoperative diagnosis of complicated diverticulitis are found to have a perforated carcinoma [22]. Intra-abdominal contamination should be washed out, and if the open colonic perforation is still leaking, it should be contained with primary closure or clamp. Colon resection should be attempted in all cases. Patients who have complications of diverticular disease are almost always best managed by not only draining any abscess and controlling peritonitis but also resecting the inflamed segment. Management with a three-stage procedure is outdated and not recommended. Finlay and Carter reported greater morbidity in patients treated with colostomy and drainage [23]. In one study from the Mayo Clinic there was a significantly higher mortality in patients treated with a colostomy and drainage (26%) versus those treated with resection (7%) [24]. The increased mortality and morbidity rates in patients who underwent three-stage operations were confirmed in other studies also [7,25,26].
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Hartmann’s procedure (resection with oversewn rectal stump and end ostomy) is the operation of choice for patients who have purulent or feculent peritonitis. Primary anastomosis is not advised in the setting of gross purulent or fecal peritonitis. After closure of the fascia, consideration should be given to allow the skin wound to heal by secondary intention or loosely reapproximate the skin edges to decrease the risk for wound infection. Mortality rates from perforated diverticulitis with fecal peritonitis have been reported to range from 12.6% to 39% [6,8,24]. Preoperative medical comorbidity and delay in appropriate surgical intervention can greatly affect these rates. As many as 30% of patients remain with a permanent colostomy after the Hartmann’s procedure, whereas those who undergo colostomy closure have a major complication rate ranging from 4% to 10% [18]. DIVERTICULITIS ASSOCIATED WITH FISTULA Most patients who have fistula formation secondary to diverticular disease do not present with acute intra-abdominal sepsis but instead develop signs and symptoms of the fistula following one or more episodes of diverticulitis. In some patients a diverticular fistula develops without a clear history of diverticulitis [18]. The most common diverticular fistulas are colovesical, which account for 68% of patients [27]. Colovesical fistulas are more common in men than in women (2:1) because the uterus serves as a barrier to separate the sigmoid colon from other hollow viscera in women. Most women who develop diverticular colovesical or colovaginal fistula have undergone a prior hysterectomy. Symptoms of colovesical fistula are primarily urologic, including cystitis (90%), pneumaturia (75%), and fecaluria (50%). Abdominal pain, hematuria, fevers, and chills can also be seen. Colovaginal fistulas are the second most common type of diverticular fistula, accounting for 25% of such cases [6]. Patients most commonly complain of vaginal discharge (90%) but may also have passage of air or stool through their vagina. Less common diverticular fistulas include coloenteric, colouterine, and colocutaneous. The entire colon should be evaluated preoperatively by colonoscopy or contrast enema to exclude cancer and inflammatory bowel disease. The diagnosis of a colovesical fistula is best confirmed by a CT scan, which establishes the diagnosis in more than 90% of patients [28]. The classic findings are sigmoid diverticula, thickening of the bladder and the colon, air in the bladder, and opacification of the fistula tract and the bladder (Fig. 4). Cystoscopy identifies the site of fistulas in approximately 90% of patients by showing a focal area of inflammation. Visualization of the fistula on cystoscopy allows for a better understanding of the location of the fistula in relation to the ureters. The location of the fistula may indicate a possible need for ureteral catheterization before operation. The diagnostic tests most useful for detecting colovaginal fistulas are a CT scan and vaginoscopy/vaginal examination, which show thickening of the vaginal cuff, air within the vagina, a focal area of granulation or erythema, and purulent or feculent drainage. Initial management includes treatment of any acute inflammation or urosepsis with appropriate antibiotics. If a patient is found to have a fistula in the
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Fig. 4. CT scan (anterior, posterior, and coronal views) showing colovesical fistula.
setting of acute diverticulitis, treatment of the diverticulitis is undertaken with intravenous antibiotics and bowel rest. Further diagnostic evaluation or treatment is deferred for 4 to 6 weeks to allow for the inflammation to resolve. A full bowel preparation is given, and the patient is placed in the Lloyd-Davies position. Ureteral stents should be considered in any patient who has a fistula located low on the bladder or near the ureteral orifices, or in a patient who has persistent inflammatory changes. A laparotomy or laparoscopy is performed to resect the involved segment of bowel with primary anastomosis. If available, omentum or other healthy, well-vascularized tissue should be placed between the anastomosis and the previously contiguous organ. The bladder site of the fistula does not require bladder resection, but only simple oversewing and Foley catheter drainage for approximately 7 to 10 days. A cystogram is typically performed before removing the catheter. The same procedure is applied for patients who have colovaginal fistula. Vaginal defects, if identified, are repaired by excising involved tissue and oversewing. DIVERTICULITIS ASSOCIATED WITH OBSTRUCTION Diverticulitis-associated stricture or large bowel obstruction usually presents in two forms: (1) acute or (2) delayed as a consequence of fibrosis. Colonic obstruction in the setting of acute diverticulitis is usually partial. Diagnosis is made by physical examination and radiographic studies. Plain abdominal radiographs and CT scan are the most useful tools in determination of diverticulitis associated with obstruction. These studies help to differentiate small bowel obstruction that may occur as a consequence of adherence of the small bowel to a focus of diverticulitis, ileus from the inflammation, or a large bowel obstruction caused by an abscess, inflammatory phlegmon, or acute stricture (Fig. 5). Prompt hydration, intravenous antibiotics, and nasogastric decompression generally lead to improvement and allow for bowel preparation. A gentle watersoluble contrast enema can help confirm the diagnosis, exclude an obstructing sigmoid carcinoma, and provide a cathartic effect to help decompress the colon [6]. Slow oral bowel preparation, gentle irrigation enemas, or both can
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Fig. 5. Patient with large bowel obstruction from diverticulitis stricture. Used with permission from Welch JP, Cohen JL. Diverticulitis. In: Souba WW, editor. ACS surgery: principles and practice. 2004. p. 1–14.
be attempted, but this procedure should be stopped immediately if recurrent symptoms develop. Frequent abdominal examinations and abdominal radiographs should be done if attempting to decompress and prepare the bowel in an obstructed patient. In a recent analysis of the management of complicated diverticulitis, large bowel obstruction was treated by resection and anastomosis in 70% of patients [8]. High-grade obstruction represents a complex problem. If the cecum is dilated to a diameter of 10 cm or greater and there is tenderness in the right lower quadrant as a result of the obstruction, expeditious surgery is necessary because of the risk for cecal necrosis and perforation. High-grade obstruction with fecal loading of the colon is usually managed by performing a Hartmann procedure, though on-table lavage with resection and primary anastomosis with or without a diverting loop ileostomy may be considered [6,10,12]. To consider a one-stage approach, conditions should be made optimal before a primary anastomosis is performed. The patient should have a low-risk preoperative health status and be hemodynamically stable before and during the operation. The bowel must have a good blood supply, healthy resection margins, lack of tension, and lack of surrounding inflammation. Relative contraindications to primary anastomosis include high-risk patients (severe medical problems, poor nutrition, high-dose steroids or immunocompromised, history of local radiation), presence of edematous bowel with questionable viability, poor blood supply, hemodynamically unstable, and presence of purulent or feculent peritonitis.
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In those patients in whom a preoperative mechanical bowel preparation was not possible and the proximal colon is loaded with feces, but when other conditions favor an anastomosis, on-table lavage may be performed. Mortality rates range from 1% to 7% and anastomotic leak rates range from 1% to 4% in patients who have undergone on-table lavage followed by primary anastomosis [8,12,18]. This technique adds approximately 30 to 45 minutes to the operation. On-table lavage requires mobilization of both flexures of the colon. A large, soft catheter is introduced by way of an appendicostomy or through a distal ileal enterotomy surrounded by a pursestring. The colon is intubated at the proximal resection margin with a long piece of sterile corrugated anesthesia tubing, which is passed off the operating table so the effluent can be collected. Several liters of saline are infused by way of the proximal catheter. A noncrushing bowel clamp is placed on the distal ileum proximal to the infusing catheter to prevent fluid from moving retrograde. When the lavage returns are clear, 50 mL of Betadine are added to the final 500 mL of saline infusate. After completion of the lavage, the catheter and tubing are removed and the appendectomy completed or the ileotomy repaired [29] (Fig. 6). The rectal stump can be lavaged until clear with proctoscopy. A primary anastomosis can then be performed in a routine manner. A dedicated preformed kit that is easily accessible in the operating room is necessary to perform the on-table lavage maneuver appropriately. The need for on-table lavage is controversial. Recent studies indicate no significant difference in morbidity or anastomotic leak in patients who do not receive a mechanical bowel preparation before elective sigmoid resection [30,31]. In patients who are at low risk from a health standpoint and with minimal fecal spillage, no hemodynamic instability, and healthy tissue at the margins of resection, another surgical option for treatment would be a primary anastomosis with a proximal covering stoma. The diverting stoma is closed in 8 to 12 weeks after contrast studies confirm healing. There have also been cases reported of patients undergoing successful resection and primary anastomosis in patients who have complicated diverticular disease without bowel preparation. Patients who present with a fibrotic stricture after recovery from diverticulitis usually display symptoms of a partial obstruction. Patients complain of persistent diarrhea, crampy abdominal pain, and bloating. Diagnosis is aided by CT scan, barium enema, and sigmoidoscopy. Patients are given gentle bowel preparation and proceed with a laparoscopic or open resection and primary anastomosis. DIVERTICULITIS ASSOCIATED WITH BLEEDING Lower gastrointestinal bleeding associated with acute diverticulitis is an uncommon manifestation occurring in 4% to 8.2% of patients [8,26]. Attempts are made to establish the active bleeding site by means of tagged red blood cell nuclear scans or angiography. Endoscopy may be used in select patients who have little inflammation, but is usually contraindicated in the setting of acute diverticulitis. Emergency resection is indicated if the bleeding is life-threatening and if colonic angiography and attempted embolization is unsuccessful.
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Fig. 6. On-table lavage. (A) On-table lavage diagram. (B) Intra-operative picture of on-table lavage. (C ) Full view of intra-operative on-table lavage.
GUIDELINES
In the American Society of Colon and Rectal Surgeons Practice Parameters for the Treatment of Sigmoid Diverticulitis published in 2000, sigmoid resection was recommended after one episode of complicated diverticulitis [9]. CT scan is the most useful diagnostic tool in the evaluation of complicated diverticulitis. Patients who present with obstruction, abscess, or a colovesical fistula, and diverticula may have a malignancy as the cause of their inflammation and symptoms. If there is the slightest doubt of the cause of the disease at the time of operative exploration, the assumption that a possible malignancy is present must be made and a concomitant en bloc resection of any contiguous organs or tissue should be performed.
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Percutaneous drainage of large abscesses should be considered to improve symptoms and allow for elective one-stage resection. Relative contraindications to percutaneous drainage include small abscesses, immunocompromised patients, multiloculated abscesses, and clinical deterioration. Resection and immediate anastomosis are suitable for patients who have Hinchey stage I and II diverticular abscesses/phlegmons, whereas resection with diversion (the Hartmann procedure) is the gold standard for patients who have purulent or feculent peritonitis. Three-stage procedures are associated with increased morbidity and mortality and are of historic interest only. Resect colon and fistula in one-stage procedure with simple repair of the fistula site on the contiguous organ. High-grade obstructions should be treated surgically. If select conditions present, consider one-stage procedure with or without on-table lavage. In high-risk patients, setting of inflammation, or poor conditions, the Hartmann procedure is recommended. Partial obstruction should be treated medically, followed by gentle and slow bowel preparation to allow one-stage procedure. Laparoscopic approach can be used for the treatment of Hinchey stage I and II abscess, phlegmon, or decompressed colon obstruction from stricture without significant difference compared to open. The more inflammation present at the time of the operation, however, the higher the conversion rate [17].
References [1] Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4: 53–69. [2] Waugh JM, Walt AJ. Current trends in the surgical treatment of diverticulitis of the sigmoid colon. Surg Clin N Am 1962;43:1267–76. [3] Aydin HN, Remzi FH. Diverticulitis: when and how to operate? Dig Liver Dis 2004;36: 435–45. [4] Chappius CW, Cohn I Jr. Acute colonic diverticulitis. Surg Clin N Am 1988;68:301–13. [5] Rege RV, Nahrwold DL. Diverticular disease. Curr Prob Surg 1989;26:133–89. [6] Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin N Am 1993;73:975–92. [7] Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984;200:466–78. [8] Chapman JR, Davies MM, Wolff BG, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005;243(6):876–80. [9] Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis—supporting documentation. Dis Colon Rectum 2000;43:289–97. [10] Schwesinger WH, Page CP, Gaskill HV, et al. Operative management of diverticular emergencies: strategies and outcomes. Arch Surg 2000;135:558–62. [11] Zollinger RW, Zollinger RM. Diverticular disease of the colon. Adv Surg 1971;5:255. [12] Welch JP, Cohen JL. Diverticulitis. In: Souba WW, editor. ACS surgery: principles and practice. New York: Web MD Professional Pub; 2004. p. 1–14. [13] Labs JD, Sarr MG, Fishman EK, et al. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155: 331–6. [14] Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910–7. [15] Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on surgical management—a prospective study of 542 patients. Eur Radiol 2002;12:1145–9.
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[16] Hinchey GC, Schall GH, Richards MB. Treatment of perforated diverticulitis of the colon. Adv Surg 1978;12:85. [17] Sher ME, Agachan F, Bortul M, et al. Laparoscopic surgery for diverticulitis. Surg Endosc 1997;11:264–7. [18] Kaufmann HS, Sonnenday CJ. Diverticulitis. In: Bland KI, editor. The practice of general surgery. Philadelphia: W.B. Saunders Company; 2002. p. 503–8. [19] Stabile BE, Puccio E, Van Sonnenberg E, et al. Preoperative percutaneous drainage of diverticular abscess. Am J Surg 1990;159:99–104. [20] Scheidbach H, Schneider S, Rose J, et al. Laparoscopic approach to treatment of sigmoid diverticulitis: changes in the spectrum of indications and results of a prospective, multicenter study on 1,545 patients. 2004;47(11):1883–8. [21] Kockerling F, Schneider C, Reymond MA, et al. Laparoscopic resection of sigmoid diverticulitis results of a multicenter study Laparoscopic Colorectal Surgery Study Group. Surg Endosc 1999;13:567–71. [22] Colcock BP. Surgical management of complicated diverticulitis. N Engl J Med 1958;259: 570–3. [23] Finlay IG, Carter DC. A comparison of emergency resection and staged management in perforated diverticular disease. Dis Colon Rectum 1987;30:929–33. [24] Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985;28:71–5. [25] Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71:921–7. [26] Hackford AW, Schoetz DJ, Coller JA, et al. Surgical management of complicated diverticulitis: the Lahey Clinic experience, 1967 to 1982. Dis Colon Rectum 1985;28:317–21. [27] Pontari MA, McMillen MA, Garvey RH, et al. Diagnosis and treatment of enterovesical fistulae. Am Surg 1992;58:258–63. [28] Goldman SM, Fishman EK, Gatewood OM, et al. CT in diagnosis of enterovesical fistulae. Am J Roentgenol 1985;144:1229–33. [29] Gordon PH. Malignant neoplasms of the colon. In: Gordon PH, Nivatvongs S, editors. Principles and practices of surgery for the colon, rectum, and anus. 2nd edition. St. Louis: Quality Medical Publishing; 1999. [30] Goldstone AR, Kennedy N, Metcalfe M. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92:409–14. [31] Fa-Sie-Oen P, Rounen R, Buitenweg J, et al. Mechanical bowel prep or not? Outcome of a multicenter, randomized trial in elective colon surgery. Dis Colon Rectum 2005;48: 1509–16.