How is surgery performed for diverticulitis

The new ASCRS guidelines are based on growing evidence that diverticulitis may be a primary inflammatory process, rather than the result of microperforation e.

Moreover, only 13 to 23 percent of patients experience recurrence after acute uncomplicated diverticulitis, as opposed to prior estimates of 33 percent or more see table.

I rarely have ever seen a mild to moderate diverticulitis present later as a perforation. Approximately 20 percent of individuals with diverticulosis develop at least one episode of diverticulitis. In the past, elective resection might have been recommended after a second or third recurrence.

However, the number of attacks should not be a definitive decision point in uncomplicated diverticular disease. Instead, elective surgery decisions should be individualized, based on risk of recurrence, surgical morbidity, ongoing symptoms, disease complexity and operative risk.

Remzi is adamant that age not be used as a cutoff for surgery. One study of 16, Medicare patients mean age 78 concluded that most older adults do not require surgery or have recurrent attacks after a first diverticulitis episode.

Those age 80 or older were least likely to experience a recurrence or require surgery, suggesting that the disease is relatively benign for them. Regardless of the reconstruction or diversion method chosen, the margins of resection must be the same, as they appear to be the most important contributor to the likelihood of recurrent diverticulitis after resection.

Specifically, in the presence of a colocolonic anastomosis with retained distal sigmoid colon, the odds of recurrent diverticulitis increased 4-fold compared with creation of a colorectal anastomosis. Proximally, the resection should include the thickened and chronically inflamed or fibrotic colon segment but need not remove all of the colonic diverticula. Thus, when the inflammation and fibrosis are limited to the sigmoid colon, an anastomosis from descending colon to rectum is adequate, whereas involvement up to the proximal descending colon would necessitate extended left colectomy.

Recognizing that resectional approaches to urgent colectomy incur substantial associated morbidity, there is increasing discussion of nonresectional operations for acute diverticulitis. Laparoscopic peritoneal lavage has been proposed as a damage-control operation to contain contamination and give patients with acute perforation and purulent peritonitis a bridge to elective resection with primary anastomosis.

We found 6 studies reporting results of this procedure that met inclusion criteria Table 2. However, recognizing the substantial selection bias as patients converted from lavage to resection were typically analyzed with the resection group, it is difficult to draw firm conclusions from these comparative data.

We identified 8 recent articles that fit the inclusion criteria and specifically discussed day postoperative outcomes Table 3. Some reported substantially higher postoperative complication rates, 72 , 73 likely related to the relative proportion of urgent rather than elective operations evaluated. Today, the benefit of an elective operation to avoid the risk of future sepsis must be weighed against the risk of perioperative complications, especially among elderly patients and those with extensive comorbid disease.

For the former outcome, 3 articles fulfilled our selection criteria Table 3. Time to recurrence tends to be prolonged—29 months was the median and 2 of 5 recurrences were diagnosed more than 5 years after the index diagnosis. Thaler et al 77 evaluated patients who underwent elective laparoscopic or open sigmoid colectomy and reported that postoperative recurrence was not related to the urgency of the initial operation or to surgical approach, a finding corroborated in a slightly larger survey by Andeweg et al 75 in which there was no association between an index emergency procedure and subsequent recurrent disease.

Six survey studies that examined patient-reported outcomes consistently noted that most patients had some relief of symptoms. Based on the findings of this systematic review, we compared our interpretation of the evidence and consequent recommendations with those in the most recent practice parameters published by the American Society of Colon and Rectal Surgeons.

Reviewing the published literature on surgical management of diverticulitis since the turn of the millennium, we found substantial changes in contemporary evidence that have reduced the use of urgent surgery for acute diverticulitis, 1 , 2 restricted the indications for prophylactic surgery in recurrent diverticulitis, 10 , 31 , 98 and led a movement toward generally less invasive and morbid approaches to this disease. At that time, the practice parameters of the American Society of Colon and Rectal Surgeons continued to recommend elective surgery after 2 uncomplicated episodes of diverticulitis, until the practice guideline that acknowledged the need to individualize timing of surgery.

In this review, we found further evidence to support the practice of individualizing decisions about surgery based on particular characteristics of the patient and his or her presentation. Patients may pursue an operation out of fear of emergency colectomy resulting in colostomy. However, the likelihood of such an event after an uncomplicated episode of diverticulitis in average-risk patients is quite low.

Patients who experience complications of diverticular disease, including perforation, fistula, and stricture, often do require surgical intervention. Thus, rather than relying on a number of episodes to guide surgical decision making, clear, patient-specific risk factors are needed to identify those at highest risk for morbidity with expectant management of recurrent diverticulitis. Outcomes registries have improved our recognition of patient factors contributing to operative morbidity and may help with the evaluation of surgical risk, but prognostic tools to predict the course of diverticular disease and the likelihood of important complications are lacking.

Another important component of these decisions is the patient-reported long-term functional outcomes of colectomy for diverticulitis. Most patients assume that surgery will be curative when they evaluate their options. We did find low rates of recurrent diverticulitis after resection with colorectal anastomosis. The primary limitation of this study is that the overall quality of the evidence was limited.

Retrospective observational trials and epidemiologic studies account for nearly the entire evidence base from which current practice standards are derived. Trials comparing modes of therapy were largely observational and subject to selection bias.

Wide variability in surgical technique, diagnostic criteria, and completeness, duration, and method of follow-up made comparisons between studies difficult. Diverticulitis remains a common, morbid, and costly condition for which optimal surgical management remains controversial across a number of domains. However, recent evidence suggests the safety of avoiding elective colectomy for most patients with uncomplicated disease and opens the door to modern approaches such as selective anastomosis with proximal diversion in the acute setting and laparoscopic colectomy in the elective setting.

Ongoing prospective assessments of these emerging strategies are needed to continue to improve surgical management of diverticular disease in the 21st century.

Corresponding Author: Arden M. Published Online: January 15, Author Contributions: Dr Morris had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported.

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View Large Download. Table 1. Table 2. Table 3. Table 4. Table 5. Search Terms and Strategy. Sigmoid Diverticulitis. After analyzing 80 articles, Morris and coauthors report that recent studies demonstrat a lesser role for aggressive antibiotic or surgical intervention for recurrent or chronic diverticulitis. Arden M. Save Preferences. Privacy Policy Terms of Use. This Issue. Views 41, Citations View Metrics. Twitter Facebook More LinkedIn. March Scott E. Search Strategy. Study Selection. Data Extraction.

Acute Diverticulitis. Recurrent and Chronic Diverticulitis. Technical Considerations. Outcomes of Surgery. Summary Recommendations. Back to top Article Information. Diverticulitis in the United States: changing patterns of disease and treatment.

Ann Surg. PubMed Google Scholar Crossref. Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis?

Dis Colon Rectum. Accessed April 5, Direct costs of diverticulitis in a US managed care population. Am J Pharm Benefits. Google Scholar. Ambrosetti P. Dig Dis. Colonic diverticulitis: impact of imaging on surgical management: a prospective study of patients.

Eur Radiol. Elective surgery after acute diverticulitis. Br J Surg. Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg. Temporal changes in the management of diverticulitis.

J Surg Res. Practice parameters for sigmoid diverticulitis. Diverticulitis in California from to increased rates of treatment for younger patients. Am Surg. Both kinds of fiber help prevent constipation by making stools soft and easy to pass.

As a result, constipation and hard stools are more likely to occur — causing people to strain when passing stools. This increases the pressure in the colon or intestines and may cause these pouches to form. Diverticulosis is very common. It is found in more than half of Americans over age Only a small number of these people will develop diverticulitis. Doctors are not certain what causes diverticula to become inflamed. The inflammation may begin when bacteria or stool are caught in the diverticula.

An attack of diverticulitis can develop suddenly and without warning. Most people with diverticulosis do not have any discomfort or symptoms, but they may have bloating and cramping in the lower part of the belly. Symptoms of diverticulitis are more severe and often start suddenly, but they may become worse over a few days.

The most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications.

A CT scan is generally the best test to diagnose diverticulitis. Diverticulosis is usually diagnosed on routine colonoscopy. The treatment of diverticulitis depends on the severity of your symptoms. Some people may need to be hospitalized, but most patients can be treated at home with antibiotics. At home treatment usually includes oral antibiotics, dietary restrictions, and possibly, stool softeners. Eating a high-fiber diet is sometimes the only treatment necessary.

Once these pouches have formed, you will have them for life. If you make a few simple changes in your lifestyle, you may not have diverticulitis again. Surgery is required only when complications occur, attacks keep recurring, or when people have severe attacks with little response to medication. Surgery for diverticular disease can be performed by laparoscopic or minimally invasive techniques.

Surgery involves removing part of the colon, usually the sigmoid colon, and reattaching it to the rectum. Immediate surgery may be necessary when the patient has other complications, such as perforation, a large abscess, peritonitis, complete intestinal obstruction, or severe bleeding.

In these cases, two surgeries may be needed because it is not safe to rejoin the colon right away. During the first surgery, the surgeon cleans the infected abdominal cavity, removes the portion of the affected colon, and performs a temporary colostomy, creating an opening, or stoma, in the abdomen.

Stool is collected in a pouch attached to the stoma. In the second surgery several months later, the surgeon rejoins the ends of the colon and closes the stoma.

Diverticulitis can lead to bleeding; infections; small tears, called perforations; or blockages in the colon. These complications always require treatment to prevent them from progressing and causing serious illness. Rectal bleeding from diverticula is a rare complication. Doctors believe the bleeding is caused by a small blood vessel in a diverticulum that weakens and then bursts.