Introduction
Surgical management of patients presenting with complications of diverticular disease can be elective, semi-elective, or an emergency, depending on the severity of the disease and patient comorbidities. A laparoscopic sigmoid resection is the preferred procedure in the elective setting, whereas two-stage procedures (e.g., the Hartmann procedure [HP] and primary resection with anastomosis and diversion [PRA]) are better choices in the semi-elective and emergency setting. Performing either the HP or PRA laparoscopically results in decreased morbidity and mortality rates, as well as a shorter length of hospital stay. However, a significant shift in the surgeon’s mindset is required because data suggest that minimally invasive techniques are rarely used in emergencies—in as few as 6% of cases. Although patient characteristics may preclude use of minimally invasive procedures, it is fair to say that the primary limiting factor is usually a lack of familiarity with these techniques. Laparoscopic peritoneal lavage (LPL) may be an alternative option to resection in the emergency setting, especially for Hinchey stage III patients. Although this procedure has been associated with lower morbidity and mortality rates than either laparoscopic or open HP and PRA, further studies are required to determine its role in the treatment algorithm of this disease.
The objective of the present chapter is to provide a clear and concise surgical algorithm for the management of diverticulitis, including both elective and emergency operations. Surgical management of patients presenting with recurrent episodes of diverticulitis or those who show inadequate response to optimal medical management will be discussed. Complicated diverticulitis will be reviewed separately.
Understanding Diverticular Disease and its Management
From a practical treatment standpoint, acute diverticulitis can be classified into uncomplicated and complicated disease. Generally speaking, uncomplicated disease includes patients who become asymptomatic with medical treatment. Despite being at risk of recurrent episodes, elective surgery is not indicated unless quality of life is significantly affected by the frequency or severity of these episodes.
In contrast, complicated diverticulitis is usually an indication for surgery. Complicated diverticulitis includes patients presenting with an associated abscess, fistula (colovesical, colovaginal, or colocutaneous, among others), acute colonic obstruction, or diffuse purulent or feculent peritonitis. Treatment ranges from semi-elective to emergency procedures. In some cases, emergency situations can be temporized by placement of a percutaneous drain or stent.
Patients who have persistent symptoms after an acute episode of uncomplicated diverticulitis and those in whom symptoms of partial obstruction develop will require an elective operation. Management of diverticular disease is summarized in Table 49-1 .
| Disease Classification | Presentation | Initial Management | Surgical Management |
|---|---|---|---|
| Uncomplicated diverticulitis | First episode Recurrent episode | Antibiotics and dietary changes Colonoscopy or BE after resolution of symptoms | Not indicated |
| Recurrent episodes affecting quality of life Nonresolving episode Immunocompromised patients | Antibiotics and dietary changes Colonoscopy or BE to rule out IBD, IBS, and cancer | Elective laparoscopic sigmoid resection | |
| Complicated diverticulitis | With abscess formation | Antibiotics and percutaneous drainage as needed Colonoscopy or BE once recovered | Laparoscopic sigmoid resection |
| With fistula formation | Antibiotics and dietary changes Colonoscopy or BE to rule out IBD, IBS, and cancer | Laparoscopic fistula takedown and sigmoid resection Consider omental flap | |
| With purulent peritonitis (Hinchey stage III) | Antibiotics and sepsis-directed therapies Emergent procedure required | Laparoscopic or open resection and anastomosis with/without loop ileostomy or laparoscopic Hartmann vs. open procedure Consider laparoscopic lavage | |
| With feculent peritonitis (Hinchey stage I-V) | Antibiotics and sepsis-directed therapies Emergent procedure required | Laparoscopic or open resection and anastomosis with/without loop ileostomy or laparoscopic Hartmann vs. open procedure | |
| Chronic partial obstruction | Evaluation of colon: colonoscopy or BE Rule out IBD, IBS, and cancer | Laparoscopic sigmoid resection with or without temporary diversion depending on proximal colon quality | |
| Acute colonic obstruction | Stenting as a bridge to surgery (controversial) Correct overall patient’s status Emergent procedure may be required | Laparoscopic resection and anastomosis with/without loop ileostomy or laparoscopic Hartmann vs. open procedure | |
| Acute colonic obstruction—closed-loop obstruction | Emergent procedure required Special considerations: intact vs. necrotic cecum | Laparoscopic vs. open segmental colectomy vs. total colectomy with ileorectal anastomosis or end ileostomy (necrosis present) |
Acute Uncomplicated Diverticulitis
The prevalence of diverticular disease ranges from 5% to 45% and increases with age. Eighty percent of patients respond to outpatient medical management. Treatment consists of broad-spectrum antibiotics and dietary changes once the acute event is resolved. Although the role of antibiotics during acute episodes of diverticulitis has been questioned on the basis of some recent data, antibiotics remain the primary treatment for this disease. The percentage of patients requiring hospitalization is small (20%), but this still means approximately 300,000 admissions per year at an annual cost of $1.8 billion (direct medical cost). Up to 30% of these patients will subsequently experience recurrent episodes or progress to complicated disease requiring surgery.
Who Requires Elective Surgery after Uncomplicated Diverticulitis?
As previously discussed, elective resection is indicated for patients with recurrent episodes of diverticulitis that significantly affect their quality of life. Previous practice guidelines recommended surgery after a first episode of diverticulitis in patients 50 years or younger and after two episodes of diverticulitis at any age. Current practice parameters for the treatment of sigmoid diverticulitis published by the American Society of Colon and Rectal Surgeons in 2014 are more conservative. These recommendations are now aligned with a large body of literature that has demonstrated that age at the time of the first episode of diverticulitis is not a predictor of more aggressive disease. Recommendations based on the number of prior episodes of uncomplicated diverticulitis have also come under scrutiny, and the number of prior episodes is no longer a major indicator of the need for surgery. Whereas a total of four attacks was set as a threshold at which the risk of surgery would be acceptable to reduce the number of ostomies or mortalities caused by the disease, in practice, the absolute number may not be so important. For example, four attacks over four decades is a very different situation to three attacks in 6 months. Thus indications for elective surgery in persons with uncomplicated disease should be individualized based on the severity, frequency, and the impact of these recurrences. Patients with persistent symptoms of acute diverticulitis or chronic obstruction despite adequate medical management would benefit from elective surgery. Immunocompromised patients (e.g., transplant patients, patients with collagen-vascular diseases, or patients with chronic use of steroids) constitute a separate subgroup; in this population, surgery should be considered during the first episode of diverticulitis, although surgery is not always necessary in our experience.
Laparoscopic sigmoid resection is the preferred technique for elective sigmoid colectomy because an abundance of data have shown significant differences in morbidity, mortality, length of hospital stay, and cost in favor of minimally invasive procedures. Combining laparoscopic technique with enhanced postoperative recovery programs contributes even further to optimize patient care and reduce cost and resource utilization. “Converting a hospital” from open to minimally invasive surgery is feasible as a short-term goal. This endeavor requires the addition of surgeons trained in minimally invasive colorectal procedures to the staff. Putting enhanced recovery pathways in place requires educating surgeons, patients, nurses, ancillary staff, residents, and anesthesia colleagues and allows an institution to maximize patient care and resource utilization. A decrease in cost is a direct by-product of this process.
Although both single-port minimally invasive procedures and robotic approaches have been described in the treatment of diverticular disease, these techniques may be associated with higher morbidity (i.e., hernia formation after single-site surgery) and increased overall cost and operative time (robotic surgery) when compared with conventional laparoscopy. The technical aspects of a laparoscopic sigmoid colectomy will be discussed later in this chapter.
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