Operative procedures for diverticular disease

Operative procedures for diverticular disease

The aim of emergency surgery is to control peritoneal infection; indications are generalised peritonitis and failure to respond to optimum medical management. Laparotomy for diverticular disease in the acute setting has considerable risk with mortality in most series of 15%; in the case of faecal peritonitis, mortality approaches 50%. Traditionally laparotomy and thorough washout of con - - tamination are performed and then a choice has to be made between a Hartmann’s procedure (sigmoid resection with for - mation of a left iliac fossa colostomy and closure of the rectal stump; Figure 77.15 ) and resection with colonic washout and primar y anastomosis (with consideration of a defunctioning

Figure 77.14 Colonoscopic view of right-sided diverticula. (From Niikura R, Nagata N, Akiyama J et al . Hypertension and concomitant arteriosclerotic diseases are risk factors for colonic diverticular bleed

ing: a case–control study. Int J Colorectal Dis 2012; 27 : 1137–43.)

loop ileostomy). Primary anastomosis should be used selec tively but is appealing in a young fit patient without gross contamination or overwhelming sepsis. There is evidence that simple defunctioning with a proximal stoma is associated with higher mortality than a resection of the a ff ected colon. There may be a role for emergency laparoscopy in divertic ular disease in expert hands. It allows assessment of the disease and in very selected cases a simple but thorough washout and drainage. The patient must have minimal comorbidity , be rel ativ ely stable, have no visible perforation and no gross faecal contamination. While this may avoid sigmoid resection in a select few , it remains controversial. Elective surgery is usually undertaken for management of complications. Diverticular fistulae can only be cured by resecting the a ff ected bowel, although a defunctioning stoma can ameliorate symptoms. In a colovesical fistula, once cancer has been ex cluded, the sigmoid can often be pinched o ff the bladder, the sigmoid colon resected and the bladder drained with an indwelling catheter for 7–10 days. If an anastomosis is performed, it is wise to place an omental pedicle between the bowel and bladder to prevent recurrent fistulation. These procedures can be technically challenging and ureteric stents may be advisable to reduce the risk of ureteric injury . Partial cystectomy may be required and assistance from a urological surgeon is often very helpful. Haemorrhage from diverticular disease should be distin guished from angiodysplasia. It usually responds to conser vative management and only occasionally requires resection. Where available, CT angiography is helpful to localise bleeding points and selective embolisation may control activ e bleeding. Rarely , colonoscopy may be necessary to localise the bleeding site. If the source cannot be located and bleeding continues, subtotal colectomy and ileostomy is the safest option. Indications for surgery in an elective setting, in the absence of complications of the disease, are controversial. There is undoubtedly a small number of patients with r ecurrent Edward Heyde , 1911–2004, American internist, published his findings on the association between aortic valve stenosis and angiodysplasia in a letter to the England Journal of Medicine in 1958. (with anastomosis). This could be performed laparoscopically in experienced hands with a likely swifter recovery as well as improved cosmesis. Cohort studies sug gest that of patients under 50 years old admitted with diverticulitis, 25% will have a further episode. The data may be used as an argument for o ff ering elective resection but equally indicate that 75% will not get another severe attack. Many surgeons would discuss the pros and cons of elective surgery after two emergency admis - sions, although comorbidities must be carefully considered. However, there is an increasing tendency to treat even patients with recurrent a ttacks of diverticulitis conservatively in the absence of complications. Summary box 77.12 Principles of surgical management of diverticular disease /uni25CF - /uni25CF /uni25CF /uni25CF - -

Figure 77.15 Hartmann’s procedure with an oversewn rectal stump and an end left-sided colostomy following resection of the diseased segment of sigmoid colon. Hartmann’s procedure is often the safest option in an emergency setting Primary anastomosis (with or without proximal diversion) can be considered in selected patients Elective resection may be considered for recurrent attacks or complications Laparoscopy has advantages in the elective setting but use in the emergency setting is more controversial