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The Management of the Complications of Diverticulitis of the Colon
The Management of the Complications of Diverticulitis of the Colon HOWARD A. PATTERSON, M.D., F.A.C.S.*
THE aging of our population turns our attention, more and more, to those surgical problems that tend to occur in older people. It is said that, in 1900, only one person out of 25 in this country was 65 years old or older, that the present figure is one in 12, and that in 1975 the estimated comparable figure will be one in seven. 1 This aging of the population has contributed greatly to the increased interest in diverticula of the colon and the ills to which they may lead. The problem of diverticulosis is a common one indeed. Bargen reported an incidence of 5.2 per cent in a total of over 70,000 autopsies. 2 At the Massachusetts General Hospital, approximately one-third of the patients who have barium enema studies now show diverticulosis of the colon, and 8.9 per cent show evidence of diverticulitis. Diverticulitis is rare below the age of 45, the incidence rising markedly with each subsequent decade. It is with the inflammatory consequences that we are concerned, for diverticulosis, as such, is a peaceful disease of which the host is likely to be quite unaware. Furthermore, the milder manifestations of actual diverticulitis are likely to be transient and more or less selflimited. However, surgeons are becoming aware that the severe complications of diverticulitis must be treated more aggressively and that this approach will save many patients from semi-invalidism. Better anesthesia, antibiotics, and preoperative and postoperative care have all helped bring the risk of curative operations in such cases to a low figure. In spite of this, real caution, often involving multiple-stage procedures, must be exercised. It seems an appropriate time to review the surgery of the more acute complications of colonic diverticulitis, and to point out some of the surgical pitfalls. Generally in diverticulitis we are dealing with the sigmoid portion of the colon. Diverticula in the right colon are by no means rare, but they are less likely to give trouble. In this review we are considering what • Chiej oj Surgical Service, Roosevelt Hospital; Clinical Projessor oj Surgery, College oj Physicians and surgeons, Columbia University, New York, N. Y.
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T" Howard A. Patterson Morton referred to as "diverticulitis with complications."3 He listed perforation, sinus and fistula formation, obstruction, and "masking other disease" (presumably he meant those cases in which carcinoma
Fig. 119. Barium enema in a man aged 49 who was an invalid due to severe persistent diverticulitis of the sigmoid. Colostomy was refused. Resection and anastomosis in one stage. Stormy convalescence. Now in good health 2 years later. The operation should surely have been done in stages. (The diverticula in the right colon have remained quiet.)
cannot be ruled out). To this list we should add severe bleeding, although this is a rather controversial item, and pyelophlebitis with liver abscesses-fortunately very rare. The major acute complications will now be taken up in order. PERFORATION
Acute "free" perforation into the abdominal cavity is not common, but when it occurs it is a very serious matter. The usual clinical impression is that of fulminating acute appendicitis or rupture of some other hollow viscus. The fact that the sigmoid is often in the midline or even well to the right of it may add to confusion, and the presence of gas under the diaphragm, shown in x-ray studies, may lead the clinician toward a diagnosis of perforated peptic ulcer. The patient is likely to be a man,
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to be fat, and to be extremely ill. The site of perforation (usually sigmoid) may be difficult to find in a large inflammatory mass. The tissue will be SO friable that attempted closure of the opening by sutures will not be feasible, nor will an attempt to put an omental "patch" over it accomplish much. Drainage must be established (preferably through a small left McBurney-type incision, rather than through the main exploratory
Fig. 120. Barium enema showing diverticula of right colon in a patient with a history of multiple episodes of bleeding. Subsequent cholecystectomy for calculi gave an opportunity for exploration of entire abdomen. No other likely source of bleeding was discovered.
incision). A major decision must be made on whether or not a proximal vent needs to be established. In all likelihood this need was not antici. pated before operation and the possibility of a colostomy has not been discussed with the patient, who is now under general anesthesia. One is reluctant to do a colostomy without prior permission, especially if he feels that it may not be absolutely necessary. It is obvious, too, that an acute perforation in sigmoidal diverticulitis may be quite a different matter from a penetrating wound of the sigmoid from a missile. However, the experiences in military surgery securely established the value of a proximal vent in sigmoidal perforation, and I believe that a transverse colon (right) divided colostomy should be made. Drainage and antibiotic therapy may be enough; on the other hand, they may not.
Howard A. Patterson If perforation develops more slowly and the inflammatory mass remains localized, "watchful waiting" may be rewarded. Even if a true perisigmoidal abscess has developed, it may drain spontaneously into the bowel and resolve. Unfortunately, it may drain into the bladder-and a sigmoidovesical fistula is one of the more miserable and serious complications, uniformly requiring surgical relief. If it becomes necessary to drain an abscess through the abdominal wall (usually through an oblique and more or less extraperitoneal approach) a sigmoidocutaneous fistula is likely to follow. This may persist for weeks, months or years, discharging only a small amount of purulent material and rarely feces. It may be only slightly annoying to the owner unless flare-ups occur, which happens occasionally if the exit becomes too small. One point must be emphasized, namely, that no matter how easy dissection would appear to be upon study of the x-ray plates showing the fistulous tract outlined by a radiopaque agent, one must not try to dissect out these fistulous tracts and close the sigmoid opening as one would the stump of an appendix. The sigmoid wall will not be normal enough to close properly, the "hole" is likely to be on the mesenteric side, there may be narrowing beyond the area, and success is unlikely and disaster a real possibility. If the chronic fistula is causing enough inconvenience, or if the inflammatory area in the sigmoid flares up repeatedly, resection of the diseased area by a "staged" surgical plan will be indicated. Staged operations are also useful in many cases of extensive diverticulitis of the colon (usually sigmoid) that do not perforate or obstruct but may nevertheless convert the patient into an invalid. We recently operated in this manner on a woman of 69 whose sigmoid diverticula had been demonstrated by x-ray 20 years before, but who had little if any trouble as a result of them until a year before operation. At that time the left side of the colon became a rigid, inflamed tube with swollen infected mesentery, and there were pain, fever and diarrhea variable in intensity but never clearing. There was no perforation and no obstruction, but the usual conservative measures were of no avail. One sees such cases fairly often, and curative surgery is needed in them just as it is in cases in which perforation is a complication. The trend in th€l severe cases is toward removal of the diseased colonic segment, and properly so. In addition to those abscesses that perforate into the bladder, into the bowel, or through the abdominal wall, a few perforate through the pelvic floor and appear below it. In the female the pelvic organs, especially the left adnexae, may be involved in an inflammatory mass of sigmoidal origin. These cases may be unexpectedly met by the gynecologist who anticipated a mass of adnexal origin, and may present a difficult problem in surgical judgment and management, requiring immediate decision. Allen and his associates reviewed (before the American Surgical Association, in 1953), a series of 582 patients with diverticulitis (from the Massachusetts General Hospital), sigmoid resection having been done in
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approximately one case out of five. 4 From the same hospital 11 years earlier Smithwick reported a comparable series in which only one out of ten had resections. 5 One reason for the trend is the decreased surgical risk, but an equally important factor is the realization that complications of diverticulitis are far more harmful to comfort and health than was formerly realized. Preliminary Colostomy
When resection of the badly diseased sigmoid segment is necessary, whether for acute or subacute perforation, or fistula or sinus formation, or for stubborn infection that persists in the wall and mesentery of the si.gmoid, or for obstruction in varying degree, the question of preliminary colostomy must be settled first. The trend to one-stage resection is strong. Of Allen's 114 resections, 40 were done in one stage. With careful selection of cases, preparation, and after-care, one can do these resections in one stage with a respectable mortality. The patient and the family are always grateful for the avoidance of a colostomy. However, one must not allow the desire to avoid a colostomy to lead to a course of action that will harm the patient, perhaps with fatal outcome. One-stage procedures are now feasible but only in especially favorable cases. The report of Pemberton and his associates on nearly 400 patients with diverticulitis who required operation is most impressive. 6 In the early series the mortality of resection was 14.7 per cent, while in a series of 144 patients operated on between 1940 and 1945, the mortality had been lowered to 4.2 per cent. There were many factors in this decline, especially the use of chemotherapy. However, and most important, the mortality in the second series of those patients who had a preliminary colostomy (62 per cent of the resections) was only 1.1 per cent! One can safely assume that colostomy was done in the more severe cases, and it follows that avoidance of a colostomy must have raised the mortality rate in the others. Since Pemberton's report, further advances in anesthesia, antibiotic attack on the intestinal flora, and in supportive measures for the very ill surgical patient have improved the outlook, but I firmly believe that those who try to do more and more colon resections (for diverticulitis) in one stage will regret it. Rather convincing statements are found in the surgicaUiterature that disagree with this belief. 7 The choice of operation will depend on the presence or absence of obstruction, the acuteness of the process, the extent of peridiverticulitis (especially in the mesocolon), and the presence or absence of a fistula. When in doubt, a mUltiple-stage attack should be resorted to. Even when resection and anastomosis are done at the first operation, it is safer to add a cecostomy at the same time. This can be easily done in such a way that it will close spontaneously shortly after the tube is removed. The colostomy (Fig. 121) should be a completely diverting (divided) one, but the two openings need not be separated by an area of skin, for
Howard A. Patterson the simple divided loop will give adequate diversion of fecal content. The colostomy should be made in the transverse colon, and should Qrdinarily be made on the right side of the abdomen. Many of the subsequent resections will involve complete mobilization of the splenic flexure, and a left-sided colostomy (though more convenient to manage) STAGE I
STAGE II
resected segment
Fig. 121. Stage 1, Preliminary colostomy to put the left colon at rest. Stage S, Adequate mobilization of Bplenic flexure. Resection of diseased segment of sigmoid with anastomosis. Repair of bladder at site of fistula. Stage S, Closure of colostomy. (Drawings by Miss Edith Baker.)
will handicap the surgeon at the next stage. The colostomy will bring prompt improvement in the condition of the diseased portion of the left colon in most cases. In a few the improvement is slower and less marked. There is always a temptation to close the colostomy too soon if resection is not contemplated, or to do the resection too soon if this is the planned procedure. Re-establishment of the fecal stream without· first removing the diseased segment of the sigmoid is ordinarily the road to disappointment. Only one-third of Pemberton's patients (even after the left colon had been put at rest for six to 12 months) did well after closure of the colostomy without resection. It is a sound policy to proceed with planned resection in those cases that required colostomy. Exceptions to this rule might be found largely in those patients who have suffered acute free
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perforations with little history of previous trouble, and have had emergency right colostomy plus drainage to the site of perforation. The Resection: Timing and Special Points in Technique
The interval between colostomy and resection should be at least three months, with a wait of six months or longer preferable in most cases. It must be emphasized here that this rule does not apply in those cases of diverticulitis in which carcinoma is suspected. In a definite proportion of cases the presence of carcinoma cannot be ruled out completely by clinical study or repeated x-ray studies, and even when the surgeon has the lesion in his hand, he may remain in doubt. Even when the resected specimen has been split open there may still be doubt about the matter, although most specimens of diverticulitis without carcinoma will show strikingly normal mucous membrane with the inflammatory process involving the outer coats and mesentery. If one can be reasonably sure that colonic cancer is not present, a six-months' wait between colostomy and resection will prove rewarding. The resection must be done with care, and usually requires complete mobilization of the splenic flexure. The management of the thickened diseased mesocolon is tedious, but the process usually stops a few centimeters above the pouch of Douglas, and one can spare the superior hemorrhoidal artery. For some reason, diverticula do not occur in the rectum below the peritoneal reflection. The badly diseased bowel must all be removed, so that the ends to be anastomosed will be in good condition. Those who tend to remove longer segments get better results by doing so. Adequate removal of bowel is made possible by thorough mobilization proximally. The transverse colon can be brought down almost to the level of the pouch of Douglas if need be. One often leaves a few diverticula in the remaining portion of the colon, but if these are soft and quiet and the anastomosis is adequate in size, they cause no harm. In other words, one must remove all the segment that was involved in divertic:ulitis, but some scattered areas of divertic:ulosis can safely be left in. The anastomosis is done as an "open" procedure, end-to-end, using fine catgut as an inner row, "locked" to avoid purse-stringing, and silk as an outer row. Closure of the ColostolllY
After the resection and anastomosis the patient and the surgeon are anxious to get to the colostomy closure. Here again, one is tempted to save time and expense and further colostomy nuisance. One can usually "get by" with closure in ten days, but a delay of four to six weeks is wiser. If in doubt, x-ray studies with thin barium carefully administered will give a good idea of the condition of the left colon with its recent anastomosis.
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SignlOidovesical Fistula Following Perforation
Special comment should be made about one group of "perforations" in diverticulitis-those giving rise to sigmoidovesical fistulas. These are not rare. We have also seen perisigmoidal abscess drain spontaneously through the cervical stump several years after supracervical hysterectomy. Of the last 22 sigmoid resections for diverticulitis at Roosevelt Hospital, no less than six involved sigmoidovesical fistulas. There is little trouble in persuading these patients to allow preliminary colostomy. The constant urgency and dysuria are miserable companions that clear rapidly after a divided colostomy has been done. Once again, we must mention the danger of confusing diverticulitis with cancer when both are present, and this possibility must be kept constantly in mind. Nearly a third of sigmoidovesical fistulas are caused by cancer, and in many such cases previous or recent x-ray studies will demonstrate the presence of diverticula. One may easily be deceived and delay the resection too long. Mter the preliminary colostomy, resection of the diseased segment of sigmoid and repair of the bladder are done at the second stage, plus the type of anastomosis that has already been described (see Fig. 121). The third stage consists of colostomy closure, by resection and end-to-end anastomosis. This works well, for the bowel wall in the right colon will be in good condition, and the content semiliquid. The waiting period between successive stages of the surgical plan must be adequate, and it is far better to "wait longer when in doubt." OBSTRUCTION
Acute fulminating obstruction of the left colon (Fig. 122) in older people is likely to be due to cancer or to volvulus, but may occasionally be due to diverticulitis. (One must also remember that acute small bowel obstruction may occur as a result of sigmoidal diverticulitis. I have seen three such cases, in which a loop of small bowel was so intimately involved in the inflammatory mass as to cause acute obstruction. This unusual but important problem is covered in Morton's excellent review of the whole subject of diverticulitis. 3) More commonly, in diverticulitis, the story is a long one with repeated subacute obstructive episodes, and the gradual narrowing of a long sigmoidal segment from chronic scarring. This, plus edema from a new attack, finally creates a situation demanding operation. The proximal colon will be edematous and chronically distended and thickened, and these patients usually need a real "defunctioning" operation (divided colostomy) rather than the mere establishment of a "vent." In a few very ill patients with huge cecal distention seen in the roentgenogram, a simple cecostomy will tide the patient over the emergency. (Needless to say, reliance on "long tube" decompression from above, in the presence of a competent ileoceca~ valve, is the road to disaster.) I
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have one patient of 84 who had a cecostomy for acute fuhninating obstruction due to diverticulitis more than three years ago who has had very little subsequent trouble, and no further surgery. But this is not the usual story. It is obvious that, in those cases in which cancer cannot be ruled out by repeated studies, prompt resection must be done. It is less obvious, but also true, that few patients with partial obstruction due to diverticulitis
Fig. 122. Fulminating acute obstruction of sigmoid in a woman aged 81. Emergency cecostomy. Subsequent barium enema study. No additional operative measures have been necessary. Patient now 84 and doing well. This has been a fortunate result, for resection is usually required in such a case.
will do well until resection has been done. Divided colostomy in the right side of the transverse colon will lead to improvement in the condition of the diseased part of the left colon, but restoration of the old situation will mean about 70 per cent of failures. Resection is ordinarily the wisest course, due caution being exercised in allowing plenty of time between stages. Cancer of the Sigm.oid Associated with Diverticulitis
Mention has been made, several times, of the danger of overlooking a sigmoid cancer in patients who have diverticulitis. A mass is often felt in either condition, but marked tenderness is unusual with a sigmoid neoplasm and characteristic of diverticulitis. Both conditions are fairly common and are found to coexist often enough to create a real problem to any x-ray department and to any busy surgical service. The surgeon must make the diagnosis. Any surgeon who does not carefully study the
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x-ray plates of his own patients-merely accepting typed reports-is not being fair to them or to himself. When real doubt exists, and the chance of sigmoidal cancer appears definite, the usual waiting period between colostomy and resection must be cut down for obvious reasons. In approximately one out of four cases doubt as to the presence of cancer exists at the time of resection of segmental diverticulitis. Those patients who have had repeated bleeding, those with obstruction, those who do not improve properly on medical therapy or after colostomy, and those with x-ray findings not quite typical of diverticulitis must all be suspected of harboring cancer. Eternal vigilance must be the price to pay if one is to avoid "watching" a sigmoid cancer for many months in the belief that the lesion was inflammatory. BLEEDING
The most controversial item in the list of "complications of diverticulitis" now under review is that of bleeding. Some outstanding surgeons feel that colonic diverticula are a common and important source of intestinal hemorrhage, often profuse. Others are highly skeptical, pointing out that such statements are based on exclusion of other usual sources, and that the actual demonstration of the site of bleeding in these reports is rare indeed. Four detailed case reports were recently published as examples of bleeding from diverticulosis. 8 One of the patients apparently died of pneumonia after severe rectal bleeding and no autopsy was allowed. Two had sigmoid resections in which the bleeding point was not demonstrated, although it was thought likely that "engorged granulation tissue" and diverticular "ulceration" were the cause, and the fourth had no further bleeding after resection of a portion of sigmoid in which no bleeding point was demonstrated. In the summary, it was stated that in these four cases "diverticular disease" was the "principal etiologic factor" in the massive bleeding-a statement that would surely imply some doubt about other possible factors. This is true of many such reports. In my own opinion, those who teach young surgeons should repeatedly caution them to be very hesitant about accepting diverticulosis or diverticulitis as the source of important bleeding. Any other attitude will often lead to dangerous delay in finding the real source of bleeding. It is often stated that "there is a history of bleeding" in many patients with diverticulitis, the usual estimates running between 15 and 30 per cent. One wonders what the figure would be in the entire adult population. Surely one could get a history of blood having been observed in the toilet on some occasion over the years in a high percentage. Of Allen's 114 patients who had sigmoid resection for complications of diverticulitis, five were operated on for hemorrhage. Three of these had "true massive hemorrhage." One of them had diverticulosis of almost the entire colon, and bleeding recurred after sigmoid resection. Bleeding
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did not recur after removal of the rest of the colon. Ileoproctostomy was done, diverticula (as usual) being absent from the rectum. It is impossible, in many instances, to demonstrate the actual site of bleeding---either at operation or on subsequent examination of the specimen. As to the likely mechanism, it would seem reasonable to suppose that the bleeding arises from erosion, by infection or concretions, of the vessels which, in penetrating the muscular wall of the bowel, give rise to the weak spots through which diverticula are protruded. Some investigators believe that diverticula may actually invert and protrude into the lumen,9 being then easily traumatized by the fecal stream. This behavior seems rather fantastic and must be a rare event. Stone's report, read before the American Surgical Association ten years ago, is of great interest in this general problem. 10 In a careful study of "Large Melena of Obscure Origin," he selected cases in which there were no vomiting of blood and little if any antecedent history of abdominal complaint. In most cases there was marked bleeding "out of a clear sky." A very.conservativ.e surgical attitude was considered proper and bleeding did not occur again in many of the cases. Of course, a careful study was urged to determine the source, and recurrent bleeding demanded exploration.· Careful follow-up studies of the group of 71 patients led to a division into three groups: (1) 31 cases in which the origin of the bleeding was never determined; (2) 20 cases with "possible" explanations; and (3) 21 "cases with proved causes." There were seven cases of diverticulosis in Group 2, but only by the exclusion of other possible causes were the diverticula incriminated as the source of large hemorrhage, and convincing proof was absent. Contributing to the "proven" sources of hemorrhage in the 21 cases in Group 3 were many unusual conditions (leukemia, etc.,) but not a single instance of diverticulosis. We all know that massive hemorrhage may occur from a source that is not even demonstrable at autopsy, so this is really a difficult argument to settle. A recent excellent review by Fraenkell l expresses surprise that Edwards' "admirable book" on diverticula and diverticulitis mentions only one case complicated by severe bleeding. Concluding his review, Fraenkel states that "a relationship does exist" between "heavy sudden rectal bleeding without warning" ("in the elderly") and diverticulitis. One could hardly find fault with this statement, but one should continue to view this matter with skepticism, to consider it a rare occurrence, and to search with care and diligence for other sources. There are rare instances of continuing severe bleeding in which one conclude.s, clinically, that the bleeding is coming from the colon. The clinical course may force one into exploration, but it is not often a satisfactory surgical effort. Cate's patient, a woman of 40, had two portions of colon removed within 24 hours and did well, but no bleeding point was found in the two specimens. 12 Even with multiple colotomies and the careful use of the sterile
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sigmoidoscope and cleansing irrigations, one may look in vain for a bleeding point. With upper gastrointestinal bleeding of unknown source, a partial gastrectomy is fairly likely to be helpful, but in obscure bleeding from the colon, partial colectomy in the absence of positive discovery of the bleeding area is likely to give discouraging results. In summary, one may say that diverticulosis may rarely be the source of severe bleeding, making necessary a surgical resection, but that more likely sources should be carefully sought first. SUMMARY
A brief review has been made of current surgical methods of managing the more important complications of diverticulitis of the colon, a condition that, in its milder forms, responds well to medical management. Surgical attack, when indicated, usually involves resection of the diseased colonic segment. This ordinarily requires three operations. Onestage operations can be done with a consistently low mortality only in especially favorable cases. REFERENCES 1. Baurys, W. M.: The Geriatric Problem. Bull. Guthrie Clin. 23: 238, 1954. 2. Bargen, J. A.: Diverticulitis of the Large Intestine. Coll. Papers, Mayo Clin. M-: 70-72, 1952. 3. Morton, J. J. Jr.: Diverticulitis of the Colon. Tr. Am. Surg. A. 64: 725-745,1946. 4. Welch, C. E., Allen, A. W. and Donaldson, G. A.: An Appraisal of Resection of the Colon for Diverticulitis of the Sigmoid. Tr. Am. Surg. A. 71: 44-55, 1953. 5. Smithwick, R. H.: Experience with the Surgical Management of Diverticulitis of the Sigmoid. Ann. Surg. 115: 969, 1942. 6. Pemberton, J. de J., Black, B. M. and Maino, C. R.: Progress in the Management of Diverticulitis of Sigmoid Colon. Surg., Gynec. & Obst. 85: 523-534, 1947. 7. Boyden, A. M.: The Surgical Treatment of Diverticulitis of the Colon. Ann. Surg. 132: 94-109, 1950. 8. Hoar, C. S. and Bernhard, W. F.: Colonic Bleeding and Diverticular Disease of the Colon. Surg., Gynec. & Obst. 99: 101-107, 1954. 9. Mayo, C. W.: Diverticulosis and Diverticulitis of the Colon. Coll. Papers, Mayo Olin. 45: 155-159, 1953. 10. Stone, H. B.: Large Melena of Obscure Origin. Ann. Surg. 120: 582-597, 1944. 11. Fraenkel, G. J.: Rectal Bleeding and Diverticulitis. Brit. J. Surg. 41: 643-645 (May) 1954. 12. Cate, W. R.: Colectomy in the Treatment of Massive Melena Secondary to Diverticulitis. Ann. Surg. 137: 558-560, 1953. 1160 Park Avenue New York 28, N. Y.
THE aging of our population turns our attention, more and more, to those surgical problems that tend to occur in older people. It is said that, in 1900, only one person out of 25 in this country was 65 years old or older, that the present figure is one in 12, and that in 1975 the estimated comparable figure will be one in seven. 1 This aging of the population has contributed greatly to the increased interest in diverticula of the colon and the ills to which they may lead. The problem of diverticulosis is a common one indeed. Bargen reported an incidence of 5.2 per cent in a total of over 70,000 autopsies. 2 At the Massachusetts General Hospital, approximately one-third of the patients who have barium enema studies now show diverticulosis of the colon, and 8.9 per cent show evidence of diverticulitis. Diverticulitis is rare below the age of 45, the incidence rising markedly with each subsequent decade. It is with the inflammatory consequences that we are concerned, for diverticulosis, as such, is a peaceful disease of which the host is likely to be quite unaware. Furthermore, the milder manifestations of actual diverticulitis are likely to be transient and more or less selflimited. However, surgeons are becoming aware that the severe complications of diverticulitis must be treated more aggressively and that this approach will save many patients from semi-invalidism. Better anesthesia, antibiotics, and preoperative and postoperative care have all helped bring the risk of curative operations in such cases to a low figure. In spite of this, real caution, often involving multiple-stage procedures, must be exercised. It seems an appropriate time to review the surgery of the more acute complications of colonic diverticulitis, and to point out some of the surgical pitfalls. Generally in diverticulitis we are dealing with the sigmoid portion of the colon. Diverticula in the right colon are by no means rare, but they are less likely to give trouble. In this review we are considering what • Chiej oj Surgical Service, Roosevelt Hospital; Clinical Projessor oj Surgery, College oj Physicians and surgeons, Columbia University, New York, N. Y.
451
T" Howard A. Patterson Morton referred to as "diverticulitis with complications."3 He listed perforation, sinus and fistula formation, obstruction, and "masking other disease" (presumably he meant those cases in which carcinoma
Fig. 119. Barium enema in a man aged 49 who was an invalid due to severe persistent diverticulitis of the sigmoid. Colostomy was refused. Resection and anastomosis in one stage. Stormy convalescence. Now in good health 2 years later. The operation should surely have been done in stages. (The diverticula in the right colon have remained quiet.)
cannot be ruled out). To this list we should add severe bleeding, although this is a rather controversial item, and pyelophlebitis with liver abscesses-fortunately very rare. The major acute complications will now be taken up in order. PERFORATION
Acute "free" perforation into the abdominal cavity is not common, but when it occurs it is a very serious matter. The usual clinical impression is that of fulminating acute appendicitis or rupture of some other hollow viscus. The fact that the sigmoid is often in the midline or even well to the right of it may add to confusion, and the presence of gas under the diaphragm, shown in x-ray studies, may lead the clinician toward a diagnosis of perforated peptic ulcer. The patient is likely to be a man,
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to be fat, and to be extremely ill. The site of perforation (usually sigmoid) may be difficult to find in a large inflammatory mass. The tissue will be SO friable that attempted closure of the opening by sutures will not be feasible, nor will an attempt to put an omental "patch" over it accomplish much. Drainage must be established (preferably through a small left McBurney-type incision, rather than through the main exploratory
Fig. 120. Barium enema showing diverticula of right colon in a patient with a history of multiple episodes of bleeding. Subsequent cholecystectomy for calculi gave an opportunity for exploration of entire abdomen. No other likely source of bleeding was discovered.
incision). A major decision must be made on whether or not a proximal vent needs to be established. In all likelihood this need was not antici. pated before operation and the possibility of a colostomy has not been discussed with the patient, who is now under general anesthesia. One is reluctant to do a colostomy without prior permission, especially if he feels that it may not be absolutely necessary. It is obvious, too, that an acute perforation in sigmoidal diverticulitis may be quite a different matter from a penetrating wound of the sigmoid from a missile. However, the experiences in military surgery securely established the value of a proximal vent in sigmoidal perforation, and I believe that a transverse colon (right) divided colostomy should be made. Drainage and antibiotic therapy may be enough; on the other hand, they may not.
Howard A. Patterson If perforation develops more slowly and the inflammatory mass remains localized, "watchful waiting" may be rewarded. Even if a true perisigmoidal abscess has developed, it may drain spontaneously into the bowel and resolve. Unfortunately, it may drain into the bladder-and a sigmoidovesical fistula is one of the more miserable and serious complications, uniformly requiring surgical relief. If it becomes necessary to drain an abscess through the abdominal wall (usually through an oblique and more or less extraperitoneal approach) a sigmoidocutaneous fistula is likely to follow. This may persist for weeks, months or years, discharging only a small amount of purulent material and rarely feces. It may be only slightly annoying to the owner unless flare-ups occur, which happens occasionally if the exit becomes too small. One point must be emphasized, namely, that no matter how easy dissection would appear to be upon study of the x-ray plates showing the fistulous tract outlined by a radiopaque agent, one must not try to dissect out these fistulous tracts and close the sigmoid opening as one would the stump of an appendix. The sigmoid wall will not be normal enough to close properly, the "hole" is likely to be on the mesenteric side, there may be narrowing beyond the area, and success is unlikely and disaster a real possibility. If the chronic fistula is causing enough inconvenience, or if the inflammatory area in the sigmoid flares up repeatedly, resection of the diseased area by a "staged" surgical plan will be indicated. Staged operations are also useful in many cases of extensive diverticulitis of the colon (usually sigmoid) that do not perforate or obstruct but may nevertheless convert the patient into an invalid. We recently operated in this manner on a woman of 69 whose sigmoid diverticula had been demonstrated by x-ray 20 years before, but who had little if any trouble as a result of them until a year before operation. At that time the left side of the colon became a rigid, inflamed tube with swollen infected mesentery, and there were pain, fever and diarrhea variable in intensity but never clearing. There was no perforation and no obstruction, but the usual conservative measures were of no avail. One sees such cases fairly often, and curative surgery is needed in them just as it is in cases in which perforation is a complication. The trend in th€l severe cases is toward removal of the diseased colonic segment, and properly so. In addition to those abscesses that perforate into the bladder, into the bowel, or through the abdominal wall, a few perforate through the pelvic floor and appear below it. In the female the pelvic organs, especially the left adnexae, may be involved in an inflammatory mass of sigmoidal origin. These cases may be unexpectedly met by the gynecologist who anticipated a mass of adnexal origin, and may present a difficult problem in surgical judgment and management, requiring immediate decision. Allen and his associates reviewed (before the American Surgical Association, in 1953), a series of 582 patients with diverticulitis (from the Massachusetts General Hospital), sigmoid resection having been done in
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approximately one case out of five. 4 From the same hospital 11 years earlier Smithwick reported a comparable series in which only one out of ten had resections. 5 One reason for the trend is the decreased surgical risk, but an equally important factor is the realization that complications of diverticulitis are far more harmful to comfort and health than was formerly realized. Preliminary Colostomy
When resection of the badly diseased sigmoid segment is necessary, whether for acute or subacute perforation, or fistula or sinus formation, or for stubborn infection that persists in the wall and mesentery of the si.gmoid, or for obstruction in varying degree, the question of preliminary colostomy must be settled first. The trend to one-stage resection is strong. Of Allen's 114 resections, 40 were done in one stage. With careful selection of cases, preparation, and after-care, one can do these resections in one stage with a respectable mortality. The patient and the family are always grateful for the avoidance of a colostomy. However, one must not allow the desire to avoid a colostomy to lead to a course of action that will harm the patient, perhaps with fatal outcome. One-stage procedures are now feasible but only in especially favorable cases. The report of Pemberton and his associates on nearly 400 patients with diverticulitis who required operation is most impressive. 6 In the early series the mortality of resection was 14.7 per cent, while in a series of 144 patients operated on between 1940 and 1945, the mortality had been lowered to 4.2 per cent. There were many factors in this decline, especially the use of chemotherapy. However, and most important, the mortality in the second series of those patients who had a preliminary colostomy (62 per cent of the resections) was only 1.1 per cent! One can safely assume that colostomy was done in the more severe cases, and it follows that avoidance of a colostomy must have raised the mortality rate in the others. Since Pemberton's report, further advances in anesthesia, antibiotic attack on the intestinal flora, and in supportive measures for the very ill surgical patient have improved the outlook, but I firmly believe that those who try to do more and more colon resections (for diverticulitis) in one stage will regret it. Rather convincing statements are found in the surgicaUiterature that disagree with this belief. 7 The choice of operation will depend on the presence or absence of obstruction, the acuteness of the process, the extent of peridiverticulitis (especially in the mesocolon), and the presence or absence of a fistula. When in doubt, a mUltiple-stage attack should be resorted to. Even when resection and anastomosis are done at the first operation, it is safer to add a cecostomy at the same time. This can be easily done in such a way that it will close spontaneously shortly after the tube is removed. The colostomy (Fig. 121) should be a completely diverting (divided) one, but the two openings need not be separated by an area of skin, for
Howard A. Patterson the simple divided loop will give adequate diversion of fecal content. The colostomy should be made in the transverse colon, and should Qrdinarily be made on the right side of the abdomen. Many of the subsequent resections will involve complete mobilization of the splenic flexure, and a left-sided colostomy (though more convenient to manage) STAGE I
STAGE II
resected segment
Fig. 121. Stage 1, Preliminary colostomy to put the left colon at rest. Stage S, Adequate mobilization of Bplenic flexure. Resection of diseased segment of sigmoid with anastomosis. Repair of bladder at site of fistula. Stage S, Closure of colostomy. (Drawings by Miss Edith Baker.)
will handicap the surgeon at the next stage. The colostomy will bring prompt improvement in the condition of the diseased portion of the left colon in most cases. In a few the improvement is slower and less marked. There is always a temptation to close the colostomy too soon if resection is not contemplated, or to do the resection too soon if this is the planned procedure. Re-establishment of the fecal stream without· first removing the diseased segment of the sigmoid is ordinarily the road to disappointment. Only one-third of Pemberton's patients (even after the left colon had been put at rest for six to 12 months) did well after closure of the colostomy without resection. It is a sound policy to proceed with planned resection in those cases that required colostomy. Exceptions to this rule might be found largely in those patients who have suffered acute free
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perforations with little history of previous trouble, and have had emergency right colostomy plus drainage to the site of perforation. The Resection: Timing and Special Points in Technique
The interval between colostomy and resection should be at least three months, with a wait of six months or longer preferable in most cases. It must be emphasized here that this rule does not apply in those cases of diverticulitis in which carcinoma is suspected. In a definite proportion of cases the presence of carcinoma cannot be ruled out completely by clinical study or repeated x-ray studies, and even when the surgeon has the lesion in his hand, he may remain in doubt. Even when the resected specimen has been split open there may still be doubt about the matter, although most specimens of diverticulitis without carcinoma will show strikingly normal mucous membrane with the inflammatory process involving the outer coats and mesentery. If one can be reasonably sure that colonic cancer is not present, a six-months' wait between colostomy and resection will prove rewarding. The resection must be done with care, and usually requires complete mobilization of the splenic flexure. The management of the thickened diseased mesocolon is tedious, but the process usually stops a few centimeters above the pouch of Douglas, and one can spare the superior hemorrhoidal artery. For some reason, diverticula do not occur in the rectum below the peritoneal reflection. The badly diseased bowel must all be removed, so that the ends to be anastomosed will be in good condition. Those who tend to remove longer segments get better results by doing so. Adequate removal of bowel is made possible by thorough mobilization proximally. The transverse colon can be brought down almost to the level of the pouch of Douglas if need be. One often leaves a few diverticula in the remaining portion of the colon, but if these are soft and quiet and the anastomosis is adequate in size, they cause no harm. In other words, one must remove all the segment that was involved in divertic:ulitis, but some scattered areas of divertic:ulosis can safely be left in. The anastomosis is done as an "open" procedure, end-to-end, using fine catgut as an inner row, "locked" to avoid purse-stringing, and silk as an outer row. Closure of the ColostolllY
After the resection and anastomosis the patient and the surgeon are anxious to get to the colostomy closure. Here again, one is tempted to save time and expense and further colostomy nuisance. One can usually "get by" with closure in ten days, but a delay of four to six weeks is wiser. If in doubt, x-ray studies with thin barium carefully administered will give a good idea of the condition of the left colon with its recent anastomosis.
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SignlOidovesical Fistula Following Perforation
Special comment should be made about one group of "perforations" in diverticulitis-those giving rise to sigmoidovesical fistulas. These are not rare. We have also seen perisigmoidal abscess drain spontaneously through the cervical stump several years after supracervical hysterectomy. Of the last 22 sigmoid resections for diverticulitis at Roosevelt Hospital, no less than six involved sigmoidovesical fistulas. There is little trouble in persuading these patients to allow preliminary colostomy. The constant urgency and dysuria are miserable companions that clear rapidly after a divided colostomy has been done. Once again, we must mention the danger of confusing diverticulitis with cancer when both are present, and this possibility must be kept constantly in mind. Nearly a third of sigmoidovesical fistulas are caused by cancer, and in many such cases previous or recent x-ray studies will demonstrate the presence of diverticula. One may easily be deceived and delay the resection too long. Mter the preliminary colostomy, resection of the diseased segment of sigmoid and repair of the bladder are done at the second stage, plus the type of anastomosis that has already been described (see Fig. 121). The third stage consists of colostomy closure, by resection and end-to-end anastomosis. This works well, for the bowel wall in the right colon will be in good condition, and the content semiliquid. The waiting period between successive stages of the surgical plan must be adequate, and it is far better to "wait longer when in doubt." OBSTRUCTION
Acute fulminating obstruction of the left colon (Fig. 122) in older people is likely to be due to cancer or to volvulus, but may occasionally be due to diverticulitis. (One must also remember that acute small bowel obstruction may occur as a result of sigmoidal diverticulitis. I have seen three such cases, in which a loop of small bowel was so intimately involved in the inflammatory mass as to cause acute obstruction. This unusual but important problem is covered in Morton's excellent review of the whole subject of diverticulitis. 3) More commonly, in diverticulitis, the story is a long one with repeated subacute obstructive episodes, and the gradual narrowing of a long sigmoidal segment from chronic scarring. This, plus edema from a new attack, finally creates a situation demanding operation. The proximal colon will be edematous and chronically distended and thickened, and these patients usually need a real "defunctioning" operation (divided colostomy) rather than the mere establishment of a "vent." In a few very ill patients with huge cecal distention seen in the roentgenogram, a simple cecostomy will tide the patient over the emergency. (Needless to say, reliance on "long tube" decompression from above, in the presence of a competent ileoceca~ valve, is the road to disaster.) I
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have one patient of 84 who had a cecostomy for acute fuhninating obstruction due to diverticulitis more than three years ago who has had very little subsequent trouble, and no further surgery. But this is not the usual story. It is obvious that, in those cases in which cancer cannot be ruled out by repeated studies, prompt resection must be done. It is less obvious, but also true, that few patients with partial obstruction due to diverticulitis
Fig. 122. Fulminating acute obstruction of sigmoid in a woman aged 81. Emergency cecostomy. Subsequent barium enema study. No additional operative measures have been necessary. Patient now 84 and doing well. This has been a fortunate result, for resection is usually required in such a case.
will do well until resection has been done. Divided colostomy in the right side of the transverse colon will lead to improvement in the condition of the diseased part of the left colon, but restoration of the old situation will mean about 70 per cent of failures. Resection is ordinarily the wisest course, due caution being exercised in allowing plenty of time between stages. Cancer of the Sigm.oid Associated with Diverticulitis
Mention has been made, several times, of the danger of overlooking a sigmoid cancer in patients who have diverticulitis. A mass is often felt in either condition, but marked tenderness is unusual with a sigmoid neoplasm and characteristic of diverticulitis. Both conditions are fairly common and are found to coexist often enough to create a real problem to any x-ray department and to any busy surgical service. The surgeon must make the diagnosis. Any surgeon who does not carefully study the
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x-ray plates of his own patients-merely accepting typed reports-is not being fair to them or to himself. When real doubt exists, and the chance of sigmoidal cancer appears definite, the usual waiting period between colostomy and resection must be cut down for obvious reasons. In approximately one out of four cases doubt as to the presence of cancer exists at the time of resection of segmental diverticulitis. Those patients who have had repeated bleeding, those with obstruction, those who do not improve properly on medical therapy or after colostomy, and those with x-ray findings not quite typical of diverticulitis must all be suspected of harboring cancer. Eternal vigilance must be the price to pay if one is to avoid "watching" a sigmoid cancer for many months in the belief that the lesion was inflammatory. BLEEDING
The most controversial item in the list of "complications of diverticulitis" now under review is that of bleeding. Some outstanding surgeons feel that colonic diverticula are a common and important source of intestinal hemorrhage, often profuse. Others are highly skeptical, pointing out that such statements are based on exclusion of other usual sources, and that the actual demonstration of the site of bleeding in these reports is rare indeed. Four detailed case reports were recently published as examples of bleeding from diverticulosis. 8 One of the patients apparently died of pneumonia after severe rectal bleeding and no autopsy was allowed. Two had sigmoid resections in which the bleeding point was not demonstrated, although it was thought likely that "engorged granulation tissue" and diverticular "ulceration" were the cause, and the fourth had no further bleeding after resection of a portion of sigmoid in which no bleeding point was demonstrated. In the summary, it was stated that in these four cases "diverticular disease" was the "principal etiologic factor" in the massive bleeding-a statement that would surely imply some doubt about other possible factors. This is true of many such reports. In my own opinion, those who teach young surgeons should repeatedly caution them to be very hesitant about accepting diverticulosis or diverticulitis as the source of important bleeding. Any other attitude will often lead to dangerous delay in finding the real source of bleeding. It is often stated that "there is a history of bleeding" in many patients with diverticulitis, the usual estimates running between 15 and 30 per cent. One wonders what the figure would be in the entire adult population. Surely one could get a history of blood having been observed in the toilet on some occasion over the years in a high percentage. Of Allen's 114 patients who had sigmoid resection for complications of diverticulitis, five were operated on for hemorrhage. Three of these had "true massive hemorrhage." One of them had diverticulosis of almost the entire colon, and bleeding recurred after sigmoid resection. Bleeding
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did not recur after removal of the rest of the colon. Ileoproctostomy was done, diverticula (as usual) being absent from the rectum. It is impossible, in many instances, to demonstrate the actual site of bleeding---either at operation or on subsequent examination of the specimen. As to the likely mechanism, it would seem reasonable to suppose that the bleeding arises from erosion, by infection or concretions, of the vessels which, in penetrating the muscular wall of the bowel, give rise to the weak spots through which diverticula are protruded. Some investigators believe that diverticula may actually invert and protrude into the lumen,9 being then easily traumatized by the fecal stream. This behavior seems rather fantastic and must be a rare event. Stone's report, read before the American Surgical Association ten years ago, is of great interest in this general problem. 10 In a careful study of "Large Melena of Obscure Origin," he selected cases in which there were no vomiting of blood and little if any antecedent history of abdominal complaint. In most cases there was marked bleeding "out of a clear sky." A very.conservativ.e surgical attitude was considered proper and bleeding did not occur again in many of the cases. Of course, a careful study was urged to determine the source, and recurrent bleeding demanded exploration.· Careful follow-up studies of the group of 71 patients led to a division into three groups: (1) 31 cases in which the origin of the bleeding was never determined; (2) 20 cases with "possible" explanations; and (3) 21 "cases with proved causes." There were seven cases of diverticulosis in Group 2, but only by the exclusion of other possible causes were the diverticula incriminated as the source of large hemorrhage, and convincing proof was absent. Contributing to the "proven" sources of hemorrhage in the 21 cases in Group 3 were many unusual conditions (leukemia, etc.,) but not a single instance of diverticulosis. We all know that massive hemorrhage may occur from a source that is not even demonstrable at autopsy, so this is really a difficult argument to settle. A recent excellent review by Fraenkell l expresses surprise that Edwards' "admirable book" on diverticula and diverticulitis mentions only one case complicated by severe bleeding. Concluding his review, Fraenkel states that "a relationship does exist" between "heavy sudden rectal bleeding without warning" ("in the elderly") and diverticulitis. One could hardly find fault with this statement, but one should continue to view this matter with skepticism, to consider it a rare occurrence, and to search with care and diligence for other sources. There are rare instances of continuing severe bleeding in which one conclude.s, clinically, that the bleeding is coming from the colon. The clinical course may force one into exploration, but it is not often a satisfactory surgical effort. Cate's patient, a woman of 40, had two portions of colon removed within 24 hours and did well, but no bleeding point was found in the two specimens. 12 Even with multiple colotomies and the careful use of the sterile
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sigmoidoscope and cleansing irrigations, one may look in vain for a bleeding point. With upper gastrointestinal bleeding of unknown source, a partial gastrectomy is fairly likely to be helpful, but in obscure bleeding from the colon, partial colectomy in the absence of positive discovery of the bleeding area is likely to give discouraging results. In summary, one may say that diverticulosis may rarely be the source of severe bleeding, making necessary a surgical resection, but that more likely sources should be carefully sought first. SUMMARY
A brief review has been made of current surgical methods of managing the more important complications of diverticulitis of the colon, a condition that, in its milder forms, responds well to medical management. Surgical attack, when indicated, usually involves resection of the diseased colonic segment. This ordinarily requires three operations. Onestage operations can be done with a consistently low mortality only in especially favorable cases. REFERENCES 1. Baurys, W. M.: The Geriatric Problem. Bull. Guthrie Clin. 23: 238, 1954. 2. Bargen, J. A.: Diverticulitis of the Large Intestine. Coll. Papers, Mayo Clin. M-: 70-72, 1952. 3. Morton, J. J. Jr.: Diverticulitis of the Colon. Tr. Am. Surg. A. 64: 725-745,1946. 4. Welch, C. E., Allen, A. W. and Donaldson, G. A.: An Appraisal of Resection of the Colon for Diverticulitis of the Sigmoid. Tr. Am. Surg. A. 71: 44-55, 1953. 5. Smithwick, R. H.: Experience with the Surgical Management of Diverticulitis of the Sigmoid. Ann. Surg. 115: 969, 1942. 6. Pemberton, J. de J., Black, B. M. and Maino, C. R.: Progress in the Management of Diverticulitis of Sigmoid Colon. Surg., Gynec. & Obst. 85: 523-534, 1947. 7. Boyden, A. M.: The Surgical Treatment of Diverticulitis of the Colon. Ann. Surg. 132: 94-109, 1950. 8. Hoar, C. S. and Bernhard, W. F.: Colonic Bleeding and Diverticular Disease of the Colon. Surg., Gynec. & Obst. 99: 101-107, 1954. 9. Mayo, C. W.: Diverticulosis and Diverticulitis of the Colon. Coll. Papers, Mayo Olin. 45: 155-159, 1953. 10. Stone, H. B.: Large Melena of Obscure Origin. Ann. Surg. 120: 582-597, 1944. 11. Fraenkel, G. J.: Rectal Bleeding and Diverticulitis. Brit. J. Surg. 41: 643-645 (May) 1954. 12. Cate, W. R.: Colectomy in the Treatment of Massive Melena Secondary to Diverticulitis. Ann. Surg. 137: 558-560, 1953. 1160 Park Avenue New York 28, N. Y.