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Preoperative Bowel
Preparation: Is It
Necessary?
Anna Chudnovets, MD, and Sandy Hwang Fang, MD
atients who undergo colorectal surgery for cancer and inflammatory bowel disease often have associated risk factors that impair
P
wound healing, such as chemoradiation therapy, steroid therapy, and
malnutrition. Additional complicating factors include case complexity, perineal wounds, and combined multispecialty cases. Due to the
nature of the colon and rectum yielding high bacterial inoculum and
these contributing factors, the risk of postoperative infections after
surgery is significant, with an incidence approaching 40%.
The overall objective for the use of bowel preparation in colorec-
tal surgery is to reduce postoperative complications:
1. Decrease the rate of surgical site infections (SSIs)
2. Decrease anastomotic leak rates
3. Alter gut microbiome
A bowel preparation accomplishes these goals via two mechanisms: the evacuation of fecal material from the colon and the eradication of stool bacterial load. In addition, a bowel preparation should
not alter the histologic appearance of the mucosa.
Historically, bowel preparations have created a harsh physiologic
response to the human body. Newer bowel preparation formulations
are smaller in volume, ingested in a short period of time with effective
evacuation of stool, while also decreasing gastrointestinal discomfort
and side effects, such as nausea and emesis. In addition, these newer
drugs produce no fluid shifts, electrolyte imbalances, or dehydration,
which optimizes the patient, leading into the operative stage of colorectal
surgery with goal-directed fluid therapy (GDFT) as part of the enhanced
recovery pathway or enhanced recovery after surgery (ERP or ERAS).
This chapter discusses the bowel preparation types, the efficacy of
mechanical bowel preparations (MBP) versus oral antibiotics (OA)
versus no bowel preparation, colorectal disease pathology and indications for bowel preparation, and its role in ERAS.
TYPES OF BOWEL PREPARATION
There are two types of bowel preparation: mechanical bowel preparation and oral antibiotics. MBPs are oral cathartics that clear feculent
material from the colon. OA decrease intraluminal bacterial load.
Mechanical Bowel Preparation
Two types of MBPs exist: hyperosmotic versus isosmotic (Table 1).
Hyperosmotic MBPs (e.g., magnesium citrate, sodium phosphate)
exert an osmotic effect, drawing fluid into the bowel lumen, as a
mechanism of flushing out colonic contents. Although patients are
able to tolerate ingestion of these lower volume formulations, they
cause electrolyte and fluid imbalances and dehydration. Patients
subsequently become orthostatic and may develop acute kidney
injury. Contraindications to hyperosmotic solutions include renal
failure, acute coronary syndrome, congestive heart failure, bowel
obstruction, ileus, intestinal malabsorption, and ascites. The use of
hyperosmotic MBP solutions is not recommended in current consensus guidelines for ERPs.
ERAS consensus guidelines recommend the utilization of isosmotic MBPs, which consist of osmotically balanced, nonabsorbable
solutions that do not produce significant fluid or electrolyte shifts.
Isosmotic bowel preparations are deemed safe in patients with the
comorbidities of hepatic disease, congestive heart failure, and renal
failure.
Large volume polyethylene glycol (PEG) preparations include
GoLYTELY, Colyte, NuLytely, and TriLyte. Patients have difficulty
tolerating these large-volume solutions as they are not palatable and
cause nausea and emesis in 4% to 17% of patients. New low-volume PEG (1–2 L) preparations combined with other agents have
been developed and include MiraLAX, HalfLytely, MoviPrep, and
BiPeglyte.
There are multiple studies/clinical trials and meta-analyses that
show conflicting results for the effectiveness of MBPs in regard to
surgical outcomes. In a Cochrane review in 2011, 18 randomized
controlled trials were reviewed that included 5805 participants;
2906 patients were administered MBP while 2899 received no bowel
preparation before elective colorectal surgery. There was no statistically significant difference between the MBP and non-MBP groups
in regard to anastomotic leak for colonic resections and low anterior
resection. These results are similar to a recent meta-analysis, published in 2018, evaluating eight studies with 1065 patients. However,
both studies have reported that evidence quality is low due to the
variation in bowel preparations. Because of this, MBP alone is generally not recommended for elective colorectal surgery.
Oral Antibiotics
First-line antibiotics include a combination of oral neomycin sulfate plus oral erythromycin base or oral neomycin sulfate plus oral
metronidazole (Table 2). The most common side effects are nausea
and emesis. Multiple randomized controlled trials have reported
a significant improvement in SSIs with the use of OA. Two large
studies from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) (>300,000 patients) and one
large meta-analysis of prospective studies (69,000 patients) have
confirmed that many medical centers are using OA alone for their
bowel preparations before colorectal surgery. These studies suggest
that OA alone is associated with similar SSI rates to OA plus MBP
and lower SSI rates as compared with both MBP alone and no bowel
preparation.
177
178 PREOPERATIVE BOWEL PREPARATION: IS IT NECESSARY?
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TABLE 1 Mechanical Bowel Preparations
Adjuncts to Mechanical
Preparation Agent Volume/Dose Mechanism Use
PEG (electrolyte lavage) Colyte*
GoLYTELY*
Sulfate-free PEG
(improved smell/
taste, more palatable
for patients)
Low-volume PEG and
bisacodyl tablets
(decrease volume-related discomfort
[e.g., bloating,
cramping])
Aqueous NaP solutions Fleet 90 mL with
Oral sodium phosphate
(tablet)
NuLYTELY*
TriLyte*
HalfLytely and
bisacodyl tablet
bowel prep
MiraLAX
Visicol
(discontinued)
3785 mL
4000 mL
4000 mL
4000 mL
2000 mL
255 g in
2000 mL
48 oz
additional
liquid
32–40 tablets
with 48 oz
clear liquid
No solid food for at least 2 hours
before ingestion of the solution; 240 mL (8 oz) every 10
minutes until rectal output is
clear or 4 L are consumed
No solid food for at least 2 hours
before taking the solution; 240
mL (8 oz) every 10 minutes
until rectal output is clear or 4
L are consumed
Only clear liquids on the day of
the preparation. Dosage is
four bisacodyl delayed-release tablets (5 mg) at noon.
Wait for bowel movement or
maximum of 6 hours; 240 mL
(8 oz) low-volume PEG (i.e.,
HalfLytely) or 240 mL (8 oz) of
clear liquid containing one capful of MiraLAX or other PEG3350 regimen every 10 minutes
until 2 L are consumed.
Only clear liquids can be con-
sumed on the day of preparation. Two doses of 30–45 mL
(2–3 tbsp.) of oral solution
are given at least 10–12 hours
apart. Each dose is taken with
at least 8 oz of liquid followed
by an additional minimum of
at least 16 oz of liquid. The second dose must be taken at least
3 hours before the procedure.
Dosage is 32–40 tablets: 20 tab-
lets on the evening before the
procedure and 12–20 tablets
the day of the procedure (3–5
hours before). The 20 tablets
are taken as 4 tablets every 15
minutes with 8 oz of clear liquid. Bisacodyl is prescribed by
some physicians as an adjunct.
Divided dose regimens (3 L the night
Similar efficacy to PEG
Equally effective as 4 L solutions;
May cause significant fluid shifts.
Early tablet composition included
before procedure, 1 L morning of
procedure) may improve patient tolerance. PEG is considered safer than
osmotic laxatives/NaP for patients
with electrolyte/fluid imbalances,
renal or liver insufficiency, CHF, or
renal or liver failure.
additional studies needed regarding safety
Not for use in pediatric or elderly
patients or those with bowel
obstruction, gut dysmotility, other
structural intestinal disorders, renal
or liver failure, or congestive heart
failure. NaP may cause ulceration or
mucosal abnormalities; do not use
in patients with inflammatory bowel
disease. Patients with compromised
renal function or those taking ACE
inhibitors or ARBs are at risk for
phosphate nephropathy. In 2006, the
FDA issued an alert regarding the
risk for acute phosphate nephropathy, a type of acute renal failure,
with use of oral sodium phosphate
solution or tablets.
higher concentration of microcrystalline cellulose per tablet, which
left residue obscuring the mucosal
surface. Later tablet composition
decreased microcrystalline cellulose concentration. Overall, tablet
NaP is not associated with significantly improved patient tolerance
when compared with aqueous NaP.
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TABLE 1 Mechanical Bowel Preparations—cont’d
Adjuncts to Mechanical
Preparation Agent Volume/Dose Mechanism Use
Enemas Tap water 500–1000 mL Distention and lavage of rectum
Soap suds 500–1000 mL
and distal colon
Fleet enema 135 mL
Fleet bisacodyl
Enema
10 mg 1.25 oz
37.5 mL
Fleet mineral oil 480 mL
Bisacodyl Bisacodyl 5-mg tablet Poorly absorbed diphenylmeth-
ane that stimulates colonic
peristalsis, used as adjunct for
NaP or PEG preparations
Saline laxatives Magnesium
citrate (liquid)
Picolax (sodium
250–300 mL Hyperosmotic saline laxatives
that increase motility by
increased intraluminal volume
picosulfate/
magnesium
citrate)
Senna Senna
Senokot
X-Prep Syrup
(8 mg/5 mL)
Anthraquinone derivatives (gly-
cosides and sennosides) are
activated by colonic bacteria
and directly increase the rate
of colonic motility, with a
subsequent increase in colonic
transit and reduced water and
electrolyte secretion.
Simethicone Gas-X
Mylicon
Mylanta
Generic formula-
Antiflatulent, often used to pre-
vent foam formation after PEG
preparation. Mechanism of
action is unclear.
tions (80 mg)
Metoclopramide Reglan
Generic formu-
lations also
available
5 mg Dopamine antagonist gastro-proki-
netic, increasing the amplitude
of gastric contraction, with
increased peristalsis in duode-
num and jejunum but without
change in colonic motility
Carbohydrate-
electrolyte solutions
Gatorade
E-Lyte
Generic
formulations
*Flavored options are available.
ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CHF, congestive heart failure; FDA, US Food and Drug Administration;
NaP, sodium phosphate; PEG, polyethylene glycol.
Modified from Wexner SD, Beck DE, Baron TH, et al. A consensus document on bowel preparation before colonoscopy: prepared by a task force from
the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES). Dis Colon Rectum. 2006;49:792–809.
20 oz Used with PEG and/or NaP
solution to improve flavor and
prevent NaP-related fluid and
electrolyte shifts
Routine addition of enemas to oral
preparation does not improve the
quality of bowel cleansing but does
increase patient discomfort. Use
enemas in patients presenting for
endoscopy with poor distal colon
preparation and in patients with
defunctionalized distal colon (e.g.,
Hartmann’s).
Has been found to decrease the vol-
ume of PEG preparation required
Addition of magnesium citrate to PEG
allows for lower volume preparation. Use with extreme caution in
patients with renal insufficiency or
renal failure because of exclusive
renal excretion of magnesium.
Senna with PEG may improve the
quality of preparation and reduce
volume required.
May improve lumen visualization and
patient toleration of bowel prep
May reduce nausea, bloating; does
not improve colonic cleansing
Carbohydrate-based solutions more
palatable for patients; however,
associates with a theoretical risk of
cautery-induced explosion if these
carbohydrates are metabolized by
colonic bacteria into explosive gases.
179
Currently, there is a prospective randomized controlled trial
using the Rethinking Clinical Trials (REaCT) platform and NSQIP
to compare no bowel preparation versus preoperative OA alone to
evaluate SSI rate in elective colorectal surgery. Results are pending
at this time. A similar multicenter randomized controlled trial
was performed in Spain (ORALEV) in which 536 patients were
randomized to no OA versus OA. The incidence of SSI in the no
OA group (30/269, 11%) was significantly higher than in the OA
180 PREOPERATIVE BOWEL PREPARATION: IS IT NECESSARY?
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TABLE 2 Oral Antibiotic Regimens
Oral Antibiotic
Prophylactic Regimen* Use in Prior Literature
Neomycin + erythromycin Coppa, 1988; Kaiser, 1983;
Khubchandani, 1989; Lau, 1988;
Nichols, 1973; Stellato, 1983
Metronidazole + neomycin Epsin-Basany, 005; Hanel, 1980;
Lewis, 2002; Nohr, 1990 (included
bacitracin); Reynolds, 1989
Metronidazole + kana-
mycin
Tinidazole + neomycin Peruzzo, 1987
Kanamycin + erythromycin Ishida, 2001; Kobayashi, 2007
*Each of these oral antibiotics was combined with a range of intravenous
antibiotics in the studies listed.
Modified from Bellows CF, Mills KT, Kelly TN, Gagliardi G. Combination
of oral non-absorbable and intravenous antibiotics versus intravenous
antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials. Tec h
Coloproctol.2011;15:385–395.
group (13/267, 5%) (χ2 test, p = 0.013). The no OA group had
more complications (76/269, 28%) compared with the OA group
(51/267) (P
= 0.017).
Lazorthes, 1982; Monrozies, 1983;
Takesue, 2000
TABLE 3 Our Protocol at Johns Hopkins Hospital
Medication Comments
Mechanical
bowel
preparation
Oral antibiotics Neomycin
Clear liquid diet initiated the day before surgery up until 2 hours before
surgery.
colectomies versus left colectomies or rectal resections. Studies
evaluating patients undergoing right-sided versus left-sided colectomies/proctectomies show a preventative function of OAs in
left-sided colectomies/proctectomies with an overall incidence
SSIs as 7.01% vs 15.89% (p= 0.004) and superficial SSIs as 2.34%
vs 7.01% (p= 0.03).
MiraLAX (238 g)
Bisacodyl (four
5-mg tablets)
(six 500-mg
tablets)
Metronidazole
(six 500-mg
tablets)
MiraLAX (238 g) mixed in
a clear liquid and started
at noon the day before
surgery and completed
after hourly administrations. Bisacodyl tablets
taken as an adjunct to
MiraLAX.
Taken in three doses the
day before surgery
MECHANICAL BOWEL PREP VS
ORAL ANTIBIOTICS VS NO BOWEL
PREPARATION
The combination of MBP and OA was described as early as 1973
when the Nichols-Condon bowel prep (a combination of MBP
and OA) reported a decrease in the SSI rate from 43% to 9%. In
2012, a retrospective study utilizing the Veterans Affairs Surgical
Quality Improvement Program preoperative risk and SSI outcome
data evaluated no bowel preparation versus MBP alone versus OA
alone versus MBP + OA. Those receiving no bowel preparation
had similar SSI rates to those who had MBP only (18.1% vs 20%).
Patients receiving OA alone had a SSI rate of 8.3%, and those
receiving OA + MBP had an SSI rate of 9.2%. In adjusted analysis,
the use of OA alone was associated with a 67% decrease in SSI rate
(OR = 0.33, 95% CI 0.21–0.50). OA + MBP was associated with a
57% decrease in SSI rate (OR = 0.43, 95% CI 0.34–0.55). A retrospective analysis of the NSQIP colectomy cohort from 2011 to 2012
subsequently showed that the use of OA alone decreased SSI rates,
consequently decreasing postoperative length of stay (LOS) and
readmission rates.
The rate of antibiotic resistance or Clostridium difficile infection
is similar in the OA alone, no bowel preparation, and OA + MBP
groups.
OUTCOMES OF SURGERY DEPENDENT
ON TYPE OF SURGERY
Studies have demonstrated that right colon bacterial concentrations range from 10
these numbers rise to 10
Several studies have demonstrated a lower risk of SSIs after right
6
to 107 bacteria/g of stool content, whereas
11
to 1012 bacteria/g in the rectosigmoid.
BOWEL PREPARATION IN ERAS
ERAS guidelines recommend the routine use of combined isosmotic
MBP with OA before elective colorectal surgery (Table 3). With the
addition of oral carbohydrate loading to MBP, in addition to the
emphasis on intake of clear liquids up to 2 hours before surgery as
denoted by American Society of Anesthesiologists (ASA) Fasting
Guidelines, patients undergoing elective colorectal surgery better
tolerate adverse side effects of MBP while also requiring less fluid
administration intraoperatively.
CONCLUSION
The use of isosmotic MBP + OA as part of the ERAS pathway prevents postoperative complications, such as SSIs, and reduces hospital
LOS, costs, and readmission rates. Although evidence shows that
MBP alone has not shown benefit, evidence is lacking for the use of
OA alone. Future studies, such as an ongoing prospective randomized controlled trial using the REaCT platform and NSQIP will help
to inform the perioperative benefits of OA alone.
Holubar SD, Hedrick T, Gupta R, et al. American Society for Enhanced
Recovery (ASER) and Perioperative Quality Initiative (POQI) joint
consensus statement on prevention of postoperative infection within an
enhanced recovery pathway for elective colorectal surgery. Perioperative
Medicine. 2017;6(1):1–18.
Khangura SD, La Fleur P, Argáez C, Adcock L. Bowel preparation for elective
colorectal procedures: a review of clinical effectiveness, cost-effectiveness, and guidelines. Canadian Agency for Drugs and Technologies in
Health. 2018 Jul 13. Available from: https://www.ncbi.nlm.nih.gov/books/
NBK537801/.
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181
Management of
Diverticular Disease of
the Colon
Katharina M. Scheurlen, MD, and Susan Galandiuk, MD
INTRODUCTION
Diverticular disease of the colon is common and a progressively
increasing burden on both patients and the healthcare system. This
term includes both asymptomatic diverticulosis as well as complications arising from diverticulosis that require further medical evaluation and treatment. Approximately 50% of Americans older than
60 years of age are diagnosed with diverticulosis; however, hospital
admission rates resulting from complications of the disease, such as
diverticulitis and diverticular bleeding, are specifically increasing
in patients younger than 45 years of age. Underestimation of the
prevalence of this disease in the young often leads to misdiagnosis
of diseases causing similar symptoms, such as appendicitis. Inpatient
treatment rates for diverticulitis have risen in young adults and show
geographic variation caused by dietary habits and environmental
factors.
Colonic diverticula are typically not true diverticula as they do
not involve all layers of the bowel wall, but only consist of mucosa
and submucosa protruding through the muscularis propria. Intraluminal pressure is thought to cause this herniation of mucosa through
weak points of the muscle layer, where intramural branches of the
vasa recta penetrate to deliver blood to the luminal layers of the
colonic wall. Contributing factors that cause increased intraluminal
pressure include a low-fiber diet with small-caliber stools and constipation as well as consumption of red meat. Other risk factors for
developing diverticular disease are overweight and obesity, physical
inactivity, smoking, use of nonsteroidal antiinflammatory drugs
(NSAIDs), and a positive family history. In Western countries, diverticula usually occur in the sigmoid colon, whereas in Asia, rightsided location is common.
Diverticular disease usually remains asymptomatic, but 4% to
15% of affected individuals may develop diverticulitis during their
lifetime, and another 5% to 15% develop diverticular bleeding.
Diverticulitis refers to inflammation of the diverticulum resulting
from a combination of poorly understood factors including bacterial
stasis, the presence of a fecalith, an altered microbiome, impaired
mucosal barrier function, and a subsequent inflammatory cascade.
Although its pathogenesis is not completely understood, clinical
and histopathologic findings in patients with diverticulitis show
some similarities to those found in ulcerative colitis. Certain types of
diverticulitis, such as segmental colitis associated with diverticulosis
(SCAD), is considered to be an inflammatory bowel disease, suggesting an autoimmune etiology. Recent studies suggest that genetic
predispositions involving immunomodulatory genes may also play
a role.
Diverticular bleeding is typically painless and usually occurs in
the absence of colonic inflammation. It originates from ruptured
vasa recta at either the dome or neck of the diverticulum and is
arterial. Repeated microtrauma involving mechanical and chemical
stress within the diverticular lumen leads to thinning of the mucosal
layer and subsequent rupture of arterial branches. Diverticular bleeding is more likely to occur in right-sided diverticular disease. This is
because diverticula of the right colon typically have a wider lumen,
exposing a larger mucosal surface area to luminal stress, along with
a thinner colonic wall.
This chapter will focus on evaluation and management of patients
with diverticulitis. A brief section about the evaluation and treatment
of patients with diverticular bleeding is included as this topic will
also be covered in the chapter devoted to gastrointestinal bleeding.
MANAGEMENT OF DIVERTICULITIS
Clinical Presentation and Diagnosis
Uncomplicated acute diverticulitis is typically located in the sigmoid
colon and characterized by the symptom triad of left lower quadrant
pain, fever, and leukocytosis. A mobile sigmoid colon or atypical
manifestation in other segments of the colon can lead to abdominal
pain in locations other than the left lower quadrant, such as the
suprapubic region or even the right-side of the abdomen.
Severe complications occur in approximately 25% of cases and
can complicate the diagnosis of underlying diverticulitis. Complications involve abscesses that occur in 30% of cases, fistula in
14%, and free perforation with peritonitis in 1% to 2% of patients.
Colonic stricture with subsequent bowel obstruction is uncommon.
For patients with complicated diverticulitis, medical treatment may
be ineffective, and the majority require surgical intervention. Complications can be highly variable, and differential diagnoses must
be excluded; therefore findings on physical examination and on
blood and urine analyses should be further evaluated with diagnostic imaging. Computed tomography (CT) is the mainstay imaging
modality in the assessment of acute diverticulitis and accompanying
complications. A CT of the abdomen and pelvis with intravenous
and oral contrast is used to evaluate the severity of inflammation
and the presence of bowel strictures, obstruction, and local or distant
complications such as abscesses and fistulas. In patients with contrast allergy, a noncontrast study or an alternative approach may be
performed (e.g., magnetic resonance imaging or ultrasonography),
particularly in the pregnant patient. Ultrasonography may identify a
hypoechoic colonic wall with a fecalith obstructing the diverticulum,
an adjacent bowel wall, and mesenteric edema, which may indicate
abscess formation. The diagnostic accuracy of ultrasound is, however, dependent on the examiner’s skill and experience.
Classification of diverticulitis is essential to follow a standardized
treatment algorithm that provides the highest success rates for disease management. The Hinchey classification, originally published
in 1978, is used as a basis to provide evidence-based management
strategies for patients with diverticular disease. The modification by
Wasvary et al. is widely used and is based on CT findings concerning
abscess formation and peritonitis (Table 1). Both imaging and clinical evaluation are required for a complete patient assessment.
Management of the Patient with
Acute Diverticular Disease
Uncomplicated Diverticular Disease
The inflammatory processes in uncomplicated diverticulitis (Stage
0 or Ia) are restricted to the colon only, while complicated diverticulitis shows signs of inflammation beyond the colon, involving the
peritoneum and pericolic structures. Although antibiotic therapy for
acute uncomplicated diverticulitis has been the traditional treatment
recommendation for many years, there have now been several large
prospective randomized clinical trials showing that uncomplicated
diverticulitis can be treated without antibiotics (Table 2). It will take
clinical practice a long time to follow this evidence. Much of this is
the result of established practice patterns and patient expectations.
In the event that symptoms limit oral intake or are severe enough to
warrant hospital admission, fluid resuscitation and bowel rest will
result in improvement while gradually advancing to a low-residue
diet. If antibiotics are used for diverticulitis, they should cover both
gram-negative and anaerobic bacteria, which is provided by either
ciprofloxacin plus metronidazole or levofloxacin plus metronidazole.
182 MANAGEMENT OF DIVERTICULAR DISEASE OF THE COLON
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TABLE 1 “Staging” or Grading of Diverticulitis Severity*
Hinchey Classification Modified Hinchey Classification by Wasvary
0 Mild clinical diverticulitis
I Pericolic abscess/phlegmon Ia
Ib
II Pelvic, distant intraabdominal or retroperito-
neal abscess
III Generalized purulent peritonitis III Generalized purulent peritonitis
IV Generalized fecal peritonitis IV Generalized fecal peritonitis
*Based on the Hinchey classification and modified Hinchey classification by Wasvary to reflect computed tomographic findings.
II Pelvic, distant intraabdominal or retroperitoneal abscess
Colonic wall thickening/confined pericolic inflammation
Confined pericolic or mesocolic abscess (<5 cm)
TABLE 2 Overview of Selected Multicenter Randomized Controlled Trials
Study Acronym Investigation Main Findings
DIverticulitis: AntiBiotics Or
cLose Observation?)
Antibiotika Vid Okomplicerad
Divertikulit
(Swedish for “antibiot-
ics in uncomplicated
diverticulitis”)
Outpatient versus Hospitalization
Management for
Uncomplicated Diverticulitis
Perforated DIVerticulitis:
sigmoid resection with or
without Anastomosis
LaparOscopic LAvage trial LOLA
SCANdinavian DIVerticulitis
trial
DIverticulitis–LAparoscopic
Lavage trial
DIAB-OLO Cost-effectiveness of conservative treatment
AVO D Treatment of uncomplicated diverticulitis
DIVER Hospitalization versus outpatient treatment
DIVA
(LADIES
trial)
(LADIES
trial)
SCANDIV Laparoscopic lavage versus primary resection
DILALA Laparoscopic lavage versus Hartmann’s pro-
(hospital admission plus antibiotics) versus liberal treatment (no antibiotics and
no strict need for hospital admission);
primary endpoint: time-to-full recovery
with antibiotics versus without antibiotics;
primary endpoint: complications and emergency surgery during hospital stay
in patients with uncomplicated diverticulitis; primary endpoint: treatment failure
rate of outpatient protocol, need for hospital admission
Sigmoidectomy with primary anastomosis
versus Hartmann’s procedure in purulent
perforated diverticulitis; primary endpoint: 12-month stoma-free survival rate
Laparoscopic lavage and drainage versus
Hartmann’s procedure versus sigmoidectomy with primary anastomosis; primary
endpoint: major morbidity and mortality
in patients with perforated diverticulitis;
primary endpoint: severe postoperative
complications within 90 days
cedure in patients with purulent perforated
diverticulitis; primary endpoint: number
of reoperations within 12 months
In patients with uncomplicated diver-
ticulitis, observational treatment
without antibiotics shortens hospital
stay and does not prolong recovery
No differences in diverticulitis recur-
rence, diverticulitis complications,
or emergency surgery rates (sigmoid
resection) in the long-term; antibiotic
treatment had no favorable outcome
Outpatient antibiotic treatment and diet
is effective and safe, cost-saving, and
associated with a similar quality of
life compared with hospitalization
with intravenous antibiotic treatment
Primary anastomosis leads to increased
stoma-free survival and is more
cost-effective compared with the
Hartmann’s procedure
Premature end of the LOLA group:
higher rate of in-hospital major morbidity, mortality, and reintervention
rate in the laparoscopic lavage arm
Laparoscopic lavage does not reduce
severe postoperative complications,
increases the reoperation rate, and
leads to a higher risk of missing associated colon carcinomas
Patients undergoing lavage have fewer
reoperations and equal hospital readmission and mortality rates.
Because of an increasing prevalence of Escherichia coli resistance to
fluoroquinolones worldwide, amoxicillin-clavulanate monotherapy
or trimethoprim-sulfamethoxazole plus metronidazole can be used
as an alternative.
Two randomized controlled trials showed no difference in patient
outcome comparing treatment with antibiotics versus fluid resuscitation only. The most recent trial from the Dutch Diverticular Disease
Collaborative Study Group (DIAB-OLO) demonstrated that no
difference concerning mild or serious adverse events could be found
between groups, but a significantly higher rate of adverse events
were associated with antibiotic treatment. Long-term follow-up data,
11 years after The Swedish Antibiotic Therapy of Acute Uncomplicated Colonic Diverticulitis (AVOD) trial, showed no difference
in recurrence rates, complications, surgical treatment rates for the
disease, and quality of life between the patient groups. Based on
these data, otherwise healthy patients with uncomplicated diverticulitis can be treated without antibiotics. Evidence from randomized
controlled trials has also shown that a 4-day course of intravenous
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183
antibiotics was as effective as a 7-day course, while clinical outcomes
of inpatient and outpatient antibiotic treatment in otherwise healthy
patients tolerating oral intake did not differ (DIVER trial). If a
patient’s clinical status does not improve after 5 days of treatment
with persistent fever, leukocytosis, and elevated acute-phase proteins
(C-reactive protein), further CT evaluation for an abscess should be
considered.
Patients who present with uncomplicated diverticulitis have a low
incidence (<2%) of occult colonic malignancy in contrast with those
with complicated diverticulitis, in whom the incidence is 8% to 11 %.
Colonoscopy is typically performed 6 weeks after symptom resolution, especially in those of screening age and family history. In case
of recurrent episodes affecting quality of life, smoldering disease, or
immunocompromise, elective colon resection may be indicated.
Diverticular Disease with Pericolic Abscess
Complicated diverticulitis that is accompanied by either a mesocolonic (stage Ib) or more distant abscess formation (stage II) occurs
in 15% to 40% of acute diverticulitis patients. It can be treated nonoperatively with antibiotics in an outpatient setting in stable patients
with abscesses ≤3 cm in size. Abscesses >3 cm or patients who do
Initial diagnosis
• Dietary changes (bowel rest)
• Blood examination (complete
blood count, electrolytes,
liver function tests, serum
lactate levels, (coagulation
parameters), C-reactive protein
• Urinalysis
• CT abdomen/pelvis; if contrast
allergy or pregnancy, US or MRI
not respond to antibiotic treatment alone require percutaneous
drainage, typically via a transabdominal approach (Fig. 1). Alternative approaches are transgluteal for pelvic abscesses (even though
they are associated with greater patient discomfort and a higher risk
of drain dislocation) and transvaginal or transrectal approaches.
Conservative treatment strategies are typically effective with small
abscesses, with an overall success rate in 80% of patients presenting
such abscesses. There is a failure rate of up to 34% with nonoperative
treatment of abscesses >3 cm in size.
If the patient is in stable condition with nonoperative treatment,
the diet is gradually advanced to a low-residue diet. If a CT-guided
drain is placed, decreasing white blood cell and drain output to <30
mL/day indicate when the drain can be considered for removal. In
many cases, a drain contrast study will show the size of the residual
abscess cavity and whether there is a communication to the colon.
The rate of recurrent abscesses after conservative treatment is high,
although it is considerably lower after percutaneous drainage (25%–
60% vs. 15%–25%). The overall failure rate of these nonoperative
approaches is 15% to 32%. In case of failure, surgery is indicated,
with urgent abscess drainage and colectomy, typically with primary
anastomosis and proximal diversion.
Uncomplicated diverticulitis
(Hinchey stage 0 or Ia)
Clinical patient status
determines management
Outpatient treatment
•Dietary changes
•No antibiotics vs oral
antibiotic therapy
Complicated diverticulitis
(Hinchey stage Ib or II)
Inpatient treatment
• Intravenous
no
Low-risk
patient?
yes no
Inpatient treatment
•Dietary changes
•(bowel rest)
•IV hydration
•Serial exams, labs
•No antibiotics vs
antibiotic therapy
for up to 4 days,
then oral therapy
• Serial exams, labs
oral or IV
antibiotic therapy
yes
Inpatient treatment
•Intravenous
•Serial exams, labs
with abscess
Abscess
< 3cm
•Percutaneous
drainage possible
yes
antibiotic therapy
for up to 4 days,
then oral therapy
Follow-up imaging
ultrasound/CT scan
(drain <30ml/24h)
Elective sigmoid
resection
no
Hartmann’s procedure
•Intravenous
antibiotic therapy
•Repeat CT, reevaluate for
Percutaneous
drainage Serial
exams, labs
Abscess resolution
yes
Elective sigmoid
resection
Complicated diverticulitis
with peritonitis
(Hinchey stage III or IV)
Depending on clinical
condition of patient
Primary anastomosis
with fecal diversion
Ostomy takedown
no
Primary anastomosis
with fecal diversion
Ostomy takedown
FIG. 1 Management of acute diverticulitis. This evidence-based algorithm should be individualized and modified based on the patient’s clinical course.
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Diverticular Disease with Perforation/Peritonitis
Purulent peritonitis (Hinchey III) and feculent peritonitis (Hinchey
IV) cannot be distinguished from one another clinically. Emergency
surgery with abdominal exploration is necessary for diagnosis. Hinchey
III is defined by an occult colonic diverticular perforation with abscess
formation and subsequent abscess rupture. Hinchey IV denotes a free
perforation of a diverticulum with peritoneal fecal contamination.
Emergency surgery is required in 15% to 32% of patients who are
hospitalized for acute diverticulitis. Acutely ill patients with diverticulitis and peritonitis should undergo expedited intravenous antibiotic
therapy, fluid resuscitation, and emergency surgery. Abdominal exploration, resection of the acutely inflamed colon containing the area of
perforation, and thorough peritoneal lavage should be performed.
Overall, 30-day hospital mortality after emergency colectomy as
reported by a retrospective National Surgical Quality Improvement
Program (NSQIP) study in 2013 was 5.1%. Significantly higher mortality rates up to 53% were found in patients with two or more of the
following risk factors: age >80 years, ASA class 4 or 5, elevated serum
creatinine (>1.2 mg/dL), and hypoalbuminemia (<2.5 g/dL).
Two types of colectomy can be performed: (1) resection with
primary anastomosis with or without proximal diversion (loop-ileostomy) or (2) resection with discontinuity and a Hartmann rectal
stump and proximal end colostomy. Although discontinuity with a
Hartmann stump was once the standard in an emergency setting,
several randomized controlled trials and meta-analyses have demonstrated that primary anastomosis with or without proximal diversion
yields favorable outcomes. In 2019, the DIVA arm of the LADIES
trial showed a significantly higher 12-month stoma-free survival rate
in patients receiving primary anastomosis with or without a defunctioning ileostomy compared with patients undergoing Hartmann
procedures in perforated diverticulitis (95% vs. 72%). There were no
significant differences in terms of morbidity and mortality between
groups (see Table 2).
Bowel reconstruction with closure of an end colostomy after a
Hartmann procedure is associated with higher morbidity compared
with closure of a loop ileostomy after primary anastomosis with
proximal diversion because of the extent of the actual disease and
procedure. For this reason, high-risk patients who are at substantial
risk of anastomotic leakage and major complications often never
undergo the second operation of colostomy closure and Hartmann
takedown. It is estimated that there are more than 5-fold the number
of Hartmann procedures performed than the number of Hartmann
reversals, and most of these colostomies can be considered permanent. The decision on whether bowel continuity should be restored
after resection in patients with Hinchey III or IV diverticulitis should
consider patient factors (presence of shock, hemodynamic stability,
immunosuppression, age) and intraoperative findings (quality of
tissue, presence of pan-abdominal inflammatory changes). The
experience of the respective surgeon should determine the most
appropriate procedure in these high-risk settings.
An alternative to bowel resection in case of perforated diverticulitis is laparoscopic lavage with drain placement. This procedure is not recommended with feculent perforation (Hinchey
IV). It can be considered in select patients with purulent peritonitis (Hinchey III); however, colectomy is generally preferred as
the need for secondary interventions is higher with laparoscopic
lavage. Three randomized controlled trials investigated laparoscopic
lavage in Hinchey III disease: the LOLA trial, SCANDIV trial, and
DILALA trial (see Table 2). These studies were heterogeneously
designed and focused on different techniques and endpoints. Several
meta-analyses have tried to make sense of this heterogeneity. Overall,
laparoscopic lavage was associated with a higher rate of surgical reintervention (20% vs. 7%, LALA trial) and a high rate of subsequent
abscess formation requiring drainage (20% vs. 0%, LALA trial). An
acute or elective surgical intervention was necessary in 48% of cases
following laparoscopic lavage (LALA trial). Deep surgical site infection (32% vs. 13%) and unplanned reoperation rates (27% vs. 10%)
were also higher in the lavage group (SCANDIV trial). The DILALA
trial, however, showed that the lavage group had a 45% reduced risk
of undergoing reoperations 2 years after the initial procedure.
Laparoscopic lavage is, however, an appealing approach because of its
shorter operative time and lower risk for cardiac complications, wound
infection, and stoma formation. This procedure may have a limited role
in select young patients with a low ASA score and high BMI to reduce
the risk of a stoma in the acute setting, allowing for a future elective
resection. The lack of homogenous supporting evidence does not, however, allow for a general recommendation for this procedure.
Treatment of Sequelae of Complicated Diverticulitis
Diverticular Stricture
Strictures of the colon can result from chronic inflammation in
patients with smoldering or recurrent diverticular disease. In the
case of a diverticular stricture, underlying malignancy must always
be suspected, and an oncologic resection of the diseased colonic
segment with lymph node clearance should be performed if colonoscopy cannot be performed preoperatively to confirm the diagnosis.
Diverticular Fistula
Fistulas can develop in up to 2% of patients with diverticular disease,
with colovesical fistulas representing half of all fistulas. Other types of
fistulas include colocutaneous fistulae following interventional drain
placement for abscess drainage, colovaginal fistulas, which almost
always occur in women who have undergone prior hysterectomy, or
rarely coloenteric or colouterine fistulas. Fistulas can also occur in
the presence of Crohn’s disease or cancer, and colonoscopy should be
performed to clarify their etiology. In patients with fistulas, sepsis and
clinical instability are uncommon. Patients can often be evaluated and
monitored in the outpatient setting until the time of elective surgery.
Surgical Treatment
Route of Access
Surgical approaches for colectomy in patients with diverticular disease
include open surgery with laparotomy or minimally invasive surgery
with either a laparoscopic or robotic approach. Regardless of route of
access, surgical management of diverticular disease follows the same
principles. A minimally invasive approach is preferred if expertise is
available, as this has been associated with superior outcomes in terms
of reduced postoperative morbidity and reduced hospital stay. The
robotic approach has been associated with decreased conversion rates
because of improved optics and instrument maneuverability and is
especially useful when dealing with inflammatory disease adherent
to the pelvic side wall. Compared with the laparoscopic approach,
robotic access has been associated with reduced rates of ileus and
postoperative complications and a shorter length of hospital stay, but
significantly increased hospital charges and longer operative times.
Clinical factors, such as hemodynamic stability, patient comorbidities, the presence of coexisting bowel obstruction, and prior
abdominal procedures causing adhesions determine whether min
imally invasive surgery is feasible or open surgery should be
performed. Several studies have shown that a minimally invasive
approach can be performed in the emergency setting with improved
morbidity. Clinical factors in the high-risk patient and longer operative times of laparoscopic procedures can, however, influence the
decision regarding choice of approach.
In the acute situation, it is important to mark the patient for a
possible stoma site in the sitting position and to avoid skin folds
and creases. In obese individuals, the upper abdomen may provide a
thinner abdominal wall, with easier stoma creation. Marking several
possible stoma sites is never wrong. Remember, the patient may have
the stoma a long time, and a well-placed stoma is essential.
Open access is performed via midline laparotomy. For laparoscopic
access, four port incisions are required, followed by a subsequent
suprapubic incision to remove the resected specimen. A large periumbilical camera port and two 5-mm ports in the right upper quadrant
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185
and left lower quadrant are placed. The port in the right lower quadrant should be of larger size because access to an endoscopic stapler
should be provided. Robotic access incisions are dependent on the
robotic system used. The Si robot incisions are similar to those of laparoscopic access, with modified placement of the large camera port to
the right of the umbilicus. The Xi robot requires ports oriented along
a straight diagonal line from the lower right abdomen medial to the
anterior superior iliac spine upward toward the patient’s left, with an
additional 5-mm assistant port in the right lower quadrant.
Common Surgical Themes Among All Routes of Access
1. Work from normal to abnormal. Beginning to work in a phleg-
mon can be challenging.
Open: Begin dissection proximally, freeing up retroperitoneal
structures superiorly and slowly working toward the area of
inflammation
Minimally invasive: Lateral-to-medial: same as for open
Minimally invasive: Medial-to-lateral: essentially begins in
“normal” retroperitoneal plane proceeding laterally toward
inflammation
2. Visualize the left ureter. If technical difficulties are anticipated,
ureteral stents are useful. See https://youtu.be/pVaFId9UuC4 for
use of indocyanine green in ureteral stents for easy intraoperative
visualization.
3. If not performing an anastomosis, resect the area of perforation.
There is no need to go down lower to the rectum itself because
this will make the subsequent surgery more difficult.
4. If performing an anastomosis, the distal part of the colorectal
anastomosis should lie within the upper rectum. This is most
easily located as the area where the colonic tenia confluence. If an
anastomosis is made in the sigmoid colon, there is an up to 25%
recurrence rate.
5. If extra colonic length is needed, the splenic flexure may need
to be mobilized and the inferior mesenteric vein and/or artery
may need to be divided.
6. The proximal line of transection should be in soft pliable bowel.
All of the diverticula-bearing colon does not need to be removed.
7. If there is a dense inflammatory scar around the rectum, the
rectum may need to be mobilized to allow a circular stapler to
pass.
In case of bowel reconstruction with primary anastomosis, an
end-to-end circular stapler is used to create a double-stapled or
triple-stapled anastomosis. If there is a lot of edema or an inability
to pass a stapler transanally, a hand-sewn colorectal anastomosis is
an option. In cases in which fecal diversion is appropriate, either a
protective loop-ileostomy (primary anastomosis and proximal diversion) or an end colostomy (Hartmann procedure with rectal stump
and discontinuity) is created. Placement of a drain is generally not
required if the dissection is above the level of the peritoneal reflection. In the case of a colovesical fistula, a drain is typically placed
near the bladder repair.
of NSAIDs, thrombocyte aggregation inhibitors, and anticoagulants, which is common among the elderly. Although diverticular
bleeding can cause severe blood loss, it will stop spontaneously
in approximately 80% of cases. The overall mortality rate is 2%
to 4%. Recurrent bleeding is common and occurs in up to 38% of
patients.
Diverticular disease is the underlying cause of more than 40% of
cases of lower gastrointestinal bleeding. Typically, patients present
with painless hematochezia. Initial standard management includes
establishing large-gauge peripheral intravenous access at two different sites, cardiopulmonary monitoring, and supplemental oxygen.
Initial laboratory analyses should include complete blood count,
electrolytes, liver parameters, lactate levels, and coagulation parameters if the patient is on anticoagulant therapy. Hemoglobin levels are
serially reevaluated, and blood transfusion is considered according to
the patient’s clinical status and the dynamics of changing hemoglobin
levels. A hemoglobin level of 6 g/dL absolutely indicates the need for
a blood transfusion in the acute setting. Patients with a history of
cardiovascular disease should receive blood at an Hb level of 8 g/dL,
and a level of 10 g/dL should be maintained.
Recommendations for withholding anticoagulants or antiplatelet
drugs in patients with acute diverticular bleeding are based on moderate to low quality evidence. The type of drug, the history of the patient
determining their individual thrombotic risk, and their clinical status
should all be considered. Aspirin as a primary prophylaxis for cardiovascular events generally can be continued, even perioperatively in the
case of emergent surgical treatment. In patients with a low thrombotic
risk and unstable gastrointestinal hemorrhage under warfarin therapy,
anticoagulation can be immediately reversed using prothrombin complex and vitamin K. Once the bleeding has stopped, warfarin therapy
should be restarted after an interval of 7 days. In case of high thrombotic risk (mechanical heart valve, atrial fibrillation with a prosthetic
heart valve or mitral stenosis, recent venous thromboembolic event
[within prior 3 months]), however, the pausing of warfarin therapy
has to be evaluated carefully. Anticoagulant therapy with heparin can
be considered as a transitional solution in an emergency setting. With
heparin therapy, monitoring the partial thromboplastin time (PTT)
every 6 hours is essential. Dosing should be carefully adjusted according to PTT levels and body weight.
The two main diagnostic approaches to distinguish diverticular
bleeding from other etiologies of lower gastrointestinal bleeding are
colonoscopy and computed tomography angiography (CT-A).
Endoscopic Strategies for Diverticular Bleeding
Colonoscopy is performed to identify the endoluminal source
of bleeding, while also providing an opportunity for hemostatic
intervention. Ideally, the clinically stable patient with lower gastrointestinal bleeding receives colonoscopy within 24 hours of hospital
admission, following a bowel preparation. Endoscopic treatment
includes epinephrine injection (1:10,000, 1–2 mL aliquots), bipolar
cautery, endoclipping, band ligation, or application of topical hemostatic agents (e.g., Hemospray).
Most Common Surgical Errors
1. No preoperative stoma marking
2. Anastomosis performed in the distal sigmoid colon
3. Attempt to resect all colonic diverticula
4. Very low Hartmann procedure performed, making subsequent
closure more difficult
MANAGEMENT OF DIVERTICULAR
BLEEDING
Clinical Presentation and Diagnosis
Three to five percent of patients with diverticular disease develop
diverticular bleeding, presenting as either bright red blood per
rectum, hematochezia, or melena. Risk factors include the use
Radiologic Strategies for Diverticular Bleeding
Following unsuccessful endoscopic evaluation, recurrent bleeding,
or clinical instability of a patient that does not allow for colonoscopy,
CT-A of the abdomen and pelvis is considered. CT-A sensitivity is
relatively low (85%), but the technique is sensitive enough to detect
bleeding rates of 0.3 to 0.5 mL/min. Only active bleeding sources
can be detected, which can be critical because of the intermittent
dynamic of diverticular bleeding. Minimally invasive interventional
treatment using selective angioembolization can be performed via
vasopressin infusion or coil embolization. Once the bleeding source
is identified, success rates of embolization are up to 85%.
Surgical Strategies for Diverticular Bleeding
Surgery in patients with diverticular bleeding is indicated in emergency settings with persistent or recurrent bleeding that cannot be
186 MANAGEMENT OF CHRONICULCERATIVE COLITIS
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managed via either endoscopic or angiographic approaches. Indications are transfusion of 6 units of blood within 24 hours to maintain
a hemoglobin level, persistent bleeding for 72 hours, or bleeding
recurrence after initial treatment.
If the source of bleeding cannot be identified preoperatively, a
subtotal colectomy with end ileostomy should be considered. Even
in cases of successful preoperative localization, a targeted segmental
colectomy is associated with a rebleeding rate in 14% of cases. The
mortality rate for colectomy for diverticular bleeding in an emergency setting is 25%. Overall rebleeding rates 1 year after hospital
discharge range from 4% to 42%. Therefore, a prophylactic elective
resection after initial bleeding in patients at high-risk for rebleeding
episodes can be considered.
Clinically stable patients who tolerate longer operative times should
receive colectomy via a laparoscopic approach. Hemodynamic instability and cardiovascular comorbidities indicate an open approach.
In case of subtotal colectomy, after mobilization of the distal
ileum beyond the ligament of Treves, the entire colonic mesentery is
taken down. An end ileostomy with a rectal stump is created in the
event of hemodynamic instability. In select stable patients undergoing elective surgery for diverticular bleeding, an ileorectal anastomosis can be considered.
CONCLUSION
In summary, management of diverticular disease has a significant
role in everyday clinical practice, and the therapeutic algorithm is
largely based on the patient’s clinical status and on diagnostic imaging and endoscopy to exclude the presence of complications such
as abscesses/fistula or cancer. Antibiotic therapy is a therapeutic
standard in complicated diverticulitis; however, several randomized
prospective studies have shown that they are not necessary in the
treatment of uncomplicated diverticulitis. Although patients with
recurrent disease generally benefit from clinical improvement and
elective surgery in a symptom-free interval, patients with perforated
diverticulitis require emergency surgical treatment. Once a Hartmann procedure is performed, reconstruction of fecal continuity is
challenging and, in the end, often not successful. Recent studies show
that primary anastomosis with or without a protective ileostomy can
prevent many patients from having a lifelong stoma without excess
morbidity. Stronger evidence, however, is required before including
these strategies in the treatment algorithm.
Bleeding of the lower gastrointestinal tract often originates from
diverticula, and treatment can be challenging in the acute setting
because of the use of anticoagulants or antiplatelet medication,
particularly in the elderly. Endoscopic control of bleeding and interventional angioembolization show high success rates. A laparoscopic
approach is an option in hemodynamically stable patients with
recurrent bleeding undergoing resection. In case of hemodynamic
instability, a laparotomy with resection of the respective bowel segment up to a subtotal colectomy in cases of an unknown bleeding
source must be considered.
Careful clinical examination of the patient accompanied by established diagnostic algorithms lead the way in treating the complications associated with diverticular disease.
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Management of
ChronicUlcerative
Colitis
Kirkpatrick Beekman Fergus, MD, Michael G. Kattah, MD,
PhD, and Elizabeth C. Wick, MD
INTRODUCTION
Ulcerative colitis (UC) is a chronic inflammatory bowel disorder
(IBD) characterized by inflammation in the rectum (proctitis) that
may extend proximally to include the colon (proctocolitis). Unlike
Crohn’s disease, which can affect anywhere in the gastrointestinal
(GI) tract from the mouth to the anus, UC only affects the mucosa
and submucosa of the colon and rectum. In general, UC is continuous, starting in the rectum (proctitis) and, in many patients, extending more proximally into the colon, first the sigmoid or descending
colon (left-sided or distal colitis) and, in more severe cases, proximal
to the splenic flexure (extensive or pancolitis). Patients exhibit a
range of symptoms including frequent, small-volume, bloody diarrhea, urgency, hematochezia, proctalgia, and colicky abdominal pain.
Associated hematochezia varies in frequency but is usually small
volume and typically does not cause rapid drops in hemoglobin. In
severe cases, patients can have significant weight loss, anorexia, and
fatigue. With rectal inflammation, patients can develop rectal pain,
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