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Youcanalsodoa‘loop-stoma’bysuturingthebackwallsofthetwoloopstogether and bring
thisupasaloop;subsequentstomaclosureistheneveneasier.Ari
Ifthececumisviabletherearesomethatwouldadvocateacecopexy,
asking “why remove a healthy organ that can be fixed?” To prevent
recurrence of the volvulus fix the mobile cecum to the lateral
abdominalwall(cecopexy).Startwithdecompressionofthececumby
milking its contents towards a rectal tube, for sutures hold poorly in a
distended bowel wall. Cecopexy isaccomplished bysuturing theentire
length of the cecum to the lateral abdominalwall. Use non-absorbable
materialandtakebigseromuscularbitesonthebowelandbig-deepbites
on the abdominal side. Some surgeons elevate a flap of parietal
peritoneumthatissuturedtotheanteriorwallofthececum.Myself,Iam
moreofa‘resector’thana‘pexer’,becauseIthinkcecopexiesfail.
SoinafitpatientIresect,butinariskypatientIwillpexy.
Cecostomy,either a tubeormatured to theskin,is an option thatis
mentionedintheliteratureasanalternativetocecopexy.Tomeitseems
abadidea(whyconvertasimpleandcleanprocedure(i.e.cecopexy)to
a contaminated and potentially complicated one (i.e. cecostomy)? It
shouldbeconsideredonlyindesperatesituations.
Sometimesabowel-coilgetsoutofplace
Bytwistingroundanarrowbase
Withgradualstrangulatingofthebloodsupply
Anddangerthatth’affectedcoilwilldie.
ThisisaVOLVULUSwhichyoushouldlearn
IsfromtheLatin—volvere—toturn.
ZacharyCope,TheAcuteAbdomeninRhyme
Acutecolonicpseudo-obstruction(Ogilvie’ssyndrome)
William Heneage Ogilvie (1887-1971) was not only a great British
surgeon but also a keen surgical aphorist. For example: “Personal
statistics are at the bottomof allunsound teaching;they are eithertoo
goodtobetrueortootruetobegood.”
This is an important differential diagnosis of colonic obstruction.
Pseudo-obstruction has the symptoms, signs, and radiographic
appearances of acute large bowel obstruction but there is no
mechanical blockage. The X-ray films are suggestive but a contrast
study or colonoscopy finds no obstruction. This pseudo-obstruction can
besointensethattherightcolonbecomesischemicandperforatesdue
to the high intramural pressure. The distension may be extreme,
resultinginacute,rapidlylethal,abdominalcompartmentsyndrome.
The mechanisms behind pseudo-obstruction are not known. It has
been proposed that the condition may be due to sympathetic overactivity,parasympatheticsuppression,orboth.Mostpatientsarealready
inhospitalforotherreasonswhenthepseudo-obstructiondevelops.Itis
arare but well-recognizedsequel to givingbirth,but more commonlyis
seenaftermajor non-intestinalsurgeryor trauma,oronthebackground
ofseriousmedicalillnesses.
This entity is the reason why you should not operate on a
suspectedcolonicobstructionwithoutapre-operativecolonoscopy,
contrastenemaor CT. Taking anelderly patient withmultiple pre-
morbidconditionsforalaparotomytofind‘only’adistendedcolon,
without an obstructing lesion, is a cardinal error. Avoid it! These
patients should not have surgery but be treated medically or
decompressedwithcolonoscopy:
•
For medical treatment it is suggested that neostigmine (2mg)
intravenously will effectively induce bowel movements and colonic
emptying within a few minutes. There are side effects to the
neostigmine, including bradycardia, salivation, nausea and
abdominal cramps. The patient should therefore be under close
surveillanceduringthetreatment.Wehavetriedthisafewtimes—
itdoesn’talwaysworkbutwhenitdoesyoulooklikeasuperstar!
•
Ifmedicaltreatmentisineffective,acolonoscopymaydecompress
the bowel. The target is decompression of the grossly distended
cecum; occasionally, repeated colonoscopic decompressions may
beneeded.Alargeandlongrectaltubecanbeleftin situafter the
colonoscopyforafewdays.
ThediagnosticGastrografin®enema
may occasionally also be therapeutic with the hyperosmolar
contrastmediumpromotingcolonicperistalsis.
Surgicaltreatmentisrequiredifthececumperforatesor,veryrarely,if
medical treatment fails and the cecum reaches a gigantic size. If the
cecum becomes necrotic or perforates, a right hemicolectomy is
necessary.Becausethefunctionalobstructionmustbeintheleftcolon,
a primary anastomosis is inappropriate. It is better to fashion an end
ileostomy and bring out the distal end of the colon through the same
colostomy hole, fashioning a ‘double-barrel’ stoma. This arrangement
makesiteasytorestorebowelcontinuitylateratthesiteofthecolostomy
withouttheneedtoreopentheabdomen.
When at laparotomy the cecum is distended but viable, most
surgeonswouldoptforacecostomy. Tubececostomyismessy; itis
associated with a high incidence of local complicationssuch as a fecal
leakarounditorevenintotheabdomen.Tominimize theserisks usea
soft large-bore tube and surroundits insertionsite in thececum with a
double purse-string suture; the cecostomy site should thenbe carefully
attached to the abdominal wall (as you do with a gastrostomy).
Cecostomy tubes tend to obstruct with fecal matter and need regular
flushing.Aviablealternativetotubececostomyistheformal—‘matured’
—cecostomy: simply exteriorize aportionof the cecum abovetheskin
levelandsutureittothesurroundingskin(asdepictedin Figure14.5).
This,in medicallyill patientswith pseudo-obstruction,can beperformed
underlocalanesthesia.
Torecap…
Wehavereviewedtheinitialdiagnosis,work-upandmanagementofa
colonicobstruction.Thishasincludedgeneratinga differentialdiagnosis
as well as initial management and the intra-operative decision making
that should take place. We focused primarily on cancer for this
discussion, as other chapters will deal with the emergencies that
arecausedbyinflammatoryboweldiseaseanddiverticulitis.
A colonic obstruction is a true general surgical emergency and
thesun shouldnotrise andsetona completecolonicobstruction
when the diagnosis is made. When evaluating and managing these
patients, especially in cancer, remembering what future therapies are
required for the patient is essential. Finally, as with any surgical
intervention,theextentofthe surgeryis reallydependent onthe overall
healthofthepatientaswellastheiracutecondition.
“Surgicaljudgmentcanbeabattlebetweenthebrainand
theheart.”
DavidDent
1
Bythewaythenameofthissuctionisnot‘pool’asmanythinkbutPoole,afterthenameof
the inventor Herman Poole, an American mechanical engineer from the end of the 19th
century.
Chapter28
Acutediverticulitis
JonathanE.Efron
1
TheBritishhavesuchtroublewiththeirdiverticulabecause
nooneisallowedtofart!
HaroldEllis(astoldtomyDad—GershonEfron)
The Western lifestyle and dietary habits lead to much morbidity
(obesity, diabetes… you know what) but for the general surgeon, the
formation of colonic diverticula is particularly problematic. These
outpouchings,starting to form earlyinlife from the notorious‘meatand
potatoesdiet’,can result in pain and misery for patients, and sleepless
nightsforsurgeons.
Colonic diverticula are protrusions of mucosa at points of
weaknessin thecolon’smuscularwallwherethevasarecta enter.
Theyarenot‘true’diverticulalikeMeckel’sdiverticulum,butrather
protrusionsofthemucosa.TheWesterndietleadstolessbulkystools.
Small, hard stools require greater intraluminal pressures to propel and
evacuate them (remember Laplace’s law?). These high pressures
producethediverticulaandalsoleadtohypertrophyofthebowelwall.
Diverticulosis (some call it diverticular disease) — the mere
development of diverticula (mainly in the sigmoid colon) — is
extremely prevalent in the developed world (and in some ‘third world’
populations adopting such poor Western dietary habits). In the vast
majorityofpeoplediverticulosiscausesnoproblemsatall.Insome,
however, diverticula may become inflamed leading to acute
diverticulitis—andthisiswhatwewillbetalkingabouthere.
Diverticularemergencies
Diverticularemergencies of the colon manifestin threedifferent
ways:
•
Theycanbecome inflamed or burst — this is acutediverticulitis
asdiscussedbelow…
•
They can bleed — diverticular bleeding generally leads to
significant lower GI bleeding and can be life-threatening as
discussed in Chapter 29. However, acute diverticulitis does
occasionallypresentwithrectalbleeding.Ifapatientpresents
withleftlowerquadrant(LLQ)painandtendernessassociated
with rectal bleeding, first think about ischemic colitis, then
think infectious colitis or IBD; but always keep acute
diverticulitisasapossiblediagnosis.
•
Theycanblock.Thisisuncommon—rarelywillacutediverticulitis
cause an acute obstruction. However, chronic diverticular disease
maycausea(sigmoid)strictureandeventually,obstructthecolon—
see Chapter27.
Whatcausesacutediverticulitis(surgicalpathology)?
The term ‘acute diverticulitis’ covers a wide spectrum of pathological
conditions — each correlating with a specific clinical scenario, each of
whichinturnnecessitatesselectivemanagement.
Atoperationforacutediverticulitisthesigmoidusuallyfeelslikeathick
fusiformtumor,withonlyafewdiverticula.However,therearealsocases
of minor thickening with many diverticula, one of which has perforated
and is the causeof the acute inflammation.Such observationsmake
onethinkaboutthebasicpathologyofacutediverticulitis.
Basil Morson, the famous pathologist at St Mark’s, London,
highlighted the hypertrophy of the bowel wall as the primary pathology
andweareinclinedtoacceptthis,withthe additionthat themesenteric
fat tissue also plays a role. Itis this fat thatcreeps up the bowel wall,
becomes inflamed, produces thephlegmon or abscess, andheals with
fibrosis. It is believedthatmany cases ofacutediverticulitis might
betterbetermedacutesigmoiditis—recognizingthatitisanacute
inflammationofthethickenedbowelwallandmesentery.
Ontheotherhand,whenitisadiverticulumthathasbeeneroded
byafecalith,onefindsalocalizedinflammation,whichidentifiesthe
siteoftheperforation.Incasesoffreefecalperitonitis,aperforated
diverticulumisthecausealthoughmoreoftenithasbeenwalledoff
by the mesentery or epiploic appendices to produce a pericolic
abscess.
Sometimes, the perforation occurs entirely within the mesentery,
formingamesentericphlegmon or abscess. The latter may secondarily
perforateintothefreeperitonealcavitybutusuallythisvarietyonlygives
risetominorabdominalandsystemicsigns.Occasionally,itcanproduce
septicemiainapatientwhoisunabletocontaintheperforation.
There is a strong tendency for diverticulitis and sigmoiditis to
adherelocallyand fistulate. The formation offistulas has anobscure
mechanism, and most patients with such a fistula present as nonemergency cases and often do not even give a history of previous
attacks of acute diverticulitis. Most often the fistulas are into the
bladder. The patient seeks attention for pneumaturia or persistent
urinary tract infection. Fistulas canalso communicatewith thefallopian
tubes,theuterus,smallbowelortheskin.Itisusuallythoughtthatthe
fistulaisthesequelofanabscessbutcommonlythereisnosignof
an associated abscess; if there had been one it must have been
silentanddrainedspontaneouslyviathefistuloustract.
Wefinditconvenienttothinkabouttheclinicalscenariosofacute
diverticulitisinorderofincreasingseverity:
Simplediverticulitis.
Complicateddiverticulitis:
•pericolicabscess;
•freeperforationwithpurulentperitonitis;
•freeperforationwithfecalperitonitis.
Soitseemsthat‘simple’diverticulitisand‘complicated’or‘perforative’diverticulitismaybetwo
differententities — the former not progressing to the latter — which is similar to the case of
simpleandcomplicatedacuteappendicitis,whicharealmosttwodifferentdiseases( Chapter
23).TheEditors
Simplediverticulitis
Simple diverticulitis describes inflammation that occurs without
any associated complication (no abscess, free perforation, or
fistula).
These patients present with LLQ pain. Usually there is some local
tendernessandguarding.ThemagnitudeofassociatedSIRSvariesand
sodothewhitebloodcellcountandC-reactiveprotein(CRP)levels.The
imagingofchoiceforinitialdiagnosisisaCTscanandinmostinstances
(Iam talkingabout theUSA) thistestwillhavealready beenperformed
bytheemergencyroomphysiciansbeforeyouarecalled.
Initialtreatmentisconservativewithhydrationandantibiotics—I
use a fluoroquinolone and metronidazole. If the patient is otherwise
healthywithoutnauseaandhasonlylocalizedpainandtenderness,Iwill
sendthemhome,afteradoseofi.v.antibioticsintheemergencyroom,to
continue on oral agents. If they are not tolerating liquids, have
associated comorbidities, or are immunosuppressed, I will admit
them for hydration, i.v. antibiotics, and observation. When their
pain/tenderness has resolved, they have defervesced, and are
tolerating oral intake, we discharge them on a 10-day course of
antibiotics. The vast majority of patients respond well to this
conservativeregimen.
Isitreallyacutediverticulitis?
Some authors (there are a few good randomized studies from
Scandinavia proving this point) have questioned the need for any
antibioticsinthesepatients,especially whenthey presentwithpainand
tendernessbutnofever orothersepticsignsandsymptoms.I feelthat
lowerabdominalpainwithoutanymanifestationsofSIRSshouldbe
treatedmoreasirritablebowelsyndromethandiverticulitisanddo
not necessarily treat with antibiotics. So not each and every old
manwithsomemildLLQpainandtenderness,andaCTreportof
“possible mild diverticulitis”,should be condemnedto 10 days of
antibiotics.
Every other year or so, what I am convinced is a diverticulitis
attack,turnsouttobeacancer.Therefore,Iperformacolonoscopy
on all of these patients 6 to 8 weeks after the first acute attack,
unless they have had a colonscopy within a year of the
presentation.
Our recent study has shown that the risk of cancer after uncomplicated diverticulitis is
minimal, so we have stopped routine colonoscopies for these patients unless there is some
otherreasonorcauseforsuspicion.SurgEndosc2014;28:961-6.Ari
“Missonecoloncancerandthelawyershaveafieldday.”Jon
Elective surgery after attack(s) of simple acute
diverticulitis?
What are the pros and cons? Only 20-30% of the patients who
presentwithacutediverticulitiswilleverhaveanotherattacksono
furthertherapy(aftercolonoscopy)isnecessary.Recurrentattacks
ofsimplediverticulitisdonotautomaticallyrequireresection.Each
patient should be assessed on an individual basis (e.g. age, operative
risks) and common sense used in making a decision. If a patient is in
yourofficewithfever,and leftlowerquadrantpainevery 3monthsafter
aninitialattackofdiverticulitis,youshouldremovethatsectionofsigmoid
colon.Iftheyhaveanattackevery3years,thenensurethattheyareon
fibersupplementation (the onlymedication ever tobeshown to prevent
recurrent attacks of diverticulitis) and treat the individual attacks
conservatively.Notably,recurrentattacksofacutediverticulitistend
tobemildandrarelyarecomplicated.Ontheotherhand, weshould
notforgetthatelectivecolectomies(eventhelaparoscopicones)arenot
free of complications and patients still may develop acute diverticulitis
abovetheresectedsigmoid(~5%ofthetime).
Patientsin whomIdorecommend surgeryevenafter oneattack
of uncomplicated diverticulitis are the chronically
immunosuppressed (e.g. rheumatoid arthritis or transplant
patients). These patients will continue to have issues with diverticulitis
that will become complicated. It is better to perform an elective
resection than deal with a complication such as a fistula or
perforation.BTW,Iamveryliberalinperformingaproximaldiversionin
these patients when I do operate on them for complicated acute
diverticulitis (see below). Immunosuppressed patients don’t tolerate
leakswell.
There is no doubt thatby far the most common presentation is
acute non-complicated diverticulitis.But, working ina large ‘ivory
tower’, Irarelysee thatanymore because it’susually recognized and
managedbythepatient’smedicaldoctororgastroenterologistwithoutmy
input.Theexceptiontothisistheimmunosuppressedpatient,whoI
seefourorfivetimesayearwithacutediverticulitis.
Complicateddiverticulitis
Complicated acute diverticulitis means a more serious ‘septic’
disease:anassociatedabscessorafreeperforationofeitherpusor
stool — sometimes both. Fistula formation is a not-so-acute
complication—butIwilldiscussitbelowasabonus…(Obstructiondue
todiverticulardiseaseismentionedin Chapter27.)
A convenient, albeit older classification system for complicated
diverticulitis,that associates complication withoutcomes,was proposed
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