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byE.JohnHincheyofMontreal,Canada(see Table28.1).Ifindthat
this classification helps me and my residents to individualize our
managementapproachtothesepatients(seethealgorithm Figure
28.1).Dr.Hincheydocumentedincreasedmortalityforadvancedstages;
butthisisintuitive—todaywehavebettertoolstomeasurethepatients’
severityofacutediseaseandoutcome,theAPACHEII2scoringsystem,
forexample.
We have recently developed a classification system based on clinical, radiological and
physiological parameters where the patient can be graded pre-operatively (J Trauma Acute
CareSurg2015;78:543-51).Ithasfivestages—definedin Table28.2.
Withthisclassificationtakingintoaccountpre-operativeparametersonly,thepredictedneedfor
surgeryandoutcomeparametersareshownin Table28.3.
You can find an online calculator for the system here: http://www.pmidcalc.org/?
sid=25710425&newtest=Y.
Ari
Figure28.1.Algorithmforthemanagementofcomplicateddiverticulitis.
Pericolonicabscesses(HincheyI&II)
So the patient presents with the typical LLQ/lower abdominal
symptoms and signs plus features of SIRS. CT shows a pericolic
abscess.
ThesearedefinedonaCTscanby:
•
Size: I use the arbitrary diameter of 5cm to determine the
management of an abscess. Small abscesses (<5cm) will
usually resolve with antibiotics. Anything less than 5cm is
usually too small to put a drain in anyway (or so my
radiologiststellme).Those>5cmIdrainifaccessible.
•
Location:adjacenttothecolonorwithinthemesentery(Hinchey I)
or extending into thepelvic, abdominal and retroperitonealspaces
(HincheyII).
HincheyIpatients
This in my experience is the most common variant of
‘complicateddiverticulitis’butfarrarerthan‘simplediverticulitis’—
Isee10to15suchcasesayear.
TheCTshowsfeatures ofacutesigmoiddiverticulitiswitha‘pericolic’
abscess, some free fluid around it, and often a few bubbles of
extraluminalair.Whattodo?
BTW,thefindingofextraluminalaironCTshouldnotautomaticallytriggeranoperationdueto
‘perforation’.Patients with onlypericolic air and no abscess can be managed non-operatively
with a 99% success rate and no mortality. The risk of failure of non-operative treatment in
patientswithasmallamountofdistantintraperitoneal air and no peritonitisissmall,butmuch
higher if there is abundant intraperitoneal air and fluid in the pouch of Douglas — as
documentedinyetanotherofourrecentstudies(DisColonRectum2014;57:875-81).Ari
Theseindividualstendtohavesmallabscesseswhichmostlyrespond
toconservativemanagementwithi.v.antibioticsandhydration.Theyare
notamenabletopercutaneousdrainageanddonotneedit!Instead,
theywillresolvewithconservativemanagement.
I treat these patients as I do those with non-complicated acute
diverticulitis — as long as the clinical features are improving. I often
obtainarepeatCTscan2weeksaftercompletingantibiotictherapy
todemonstratetheabscesshasresolved.Ifthisisthecase,andthe
patientisasymptomatic,thenIdon’tfeelthatthereisaneedforany
furtherintervention.
However, if the abscess has not completely resolved, I would repeat
theCTscanin4to6weekstoensureitisdecreasingorhasresolved.If
there is no change, than I discuss surgical resection with the
patient. If the abscess has resolved and they have no further
symptoms,wearedoneandIdonotrecommendelectiveresection
—thereis no need unless they havemultiple recurrent attacks or
are in persistent pain — (the latter, hopefully, not caused by irritable
bowelsyndrome…).
HincheyIIpatients
Even less common than Hinchey I, but I see five or six
patients/year.
Toremindyou:inthesecasestheabscessisextendingintothepelvis,
abdominal cavity or retroperitoneal spaces — beyond the colonic wall.
Again,commonlythereisfreelocalizedfluidandfreeair.Thesepatients
require drainage if the abscess is large (>5cm). This hastens
recovery.
Usually this is achieved with interventional radiology and the
placement of a percutaneous pigtail catheter, under either
ultrasound or CT guidance ( Chapter 46). Once the drain is
removed, if the patient is asymptomatic and has no recurrent
attacks,Iwillcontinuetoobserve.Someadvocateautomaticelective
resectionforallpatientswithresolvingcomplicatedacutediverticulitis—
however,withoutfurthersymptoms,Ithinkthisisunnecessary!
Afewpointsonpercutaneousdrainage
Interventional radiologists can drain almost anything — souse them.
Afteradrainisplaced,leaveitinuntiltheoutputhasdecreasedand
thecavityhas collapsed. I will often repeattheCTto ensure that the
cavityhascollapsedpriortopullingoutthedrain,otherwiseIfindweare
backputtinginanotherdrainthenextweek.
Anexceptiontothisispelvicabscesses. Deeppelvicabscesses
(those at the base of the cul-de-sac) may be better served by
surgicaldrainage:
•
If a lowpelvic abscess is suspectedin a woman,and can be
palpatedonvaginalexam,Iwilldraintheseintheoperatingroom
undergeneralanesthesia.Placethepatientinthelithotomyposition
andusingaspeculumorPrattbivalveretractorexaminethevagina.
Ifyousee or palpate a bulge, incise and draintheabscess.If you
wish you may leave a Penrose drain for a few days, but that is
mostlynotnecessary.Rarelywillthepatientdevelopa(colovaginal)
fistulaandevenifitdoesdevelopitresolvesquickly.
•
Similarly,ifyoupalpatetheabscessonrectalexam,drain it in
the operating room through therectum. You willrelieve thesepsis
and the rectum heals rapidly. If a fistula develops from the
sigmoid colon to the rectum, who cares? It is usually
asymptomatic. Most of the time the cavity collapses and
nothingelseneedstobedone.
Finally, if the patient has an abscess that is surrounded by
intestine making percutaneous drainage impossible, consider
laparoscopic drainage. If you are able to laparoscopically drain the
abscess,andnocolonperforationisseen,thencleanoutthecavityand
leave a drain; if the patient recovers you are done — nothing else is
needed.Ifsymptomspersistyoucancomebackin8weekstoperforma
laparoscopiccolectomy.
So,asyousee,themajorityofcomplicatedHincheyIorIIpatientsdonotneedanysurgery—
not during the acute episode, nor later on. That you can do a lap colectomy… and it is
‘sooooooooeasy’doesnotmeanthatyoushoulduseyourskillsindiscriminately!
Peritonitis(HincheyIII&IV)
Thesearepatientswith‘real’perforateddiverticulitis—thereisa
‘hole’inthecolonatthesiteofthe(sigmoid)diverticulumlettingout
coloniccontentstoinvadetheadjacenttissues.
HincheyIIIpatients
Very rare — I’m only seeing one to two patients a year. What
aboutyou?
These patients suffer from purulent peritonitis or PID (“pus in der
Bauch…” aswesay inBaltimore,with itsrich Germanheritage).They
presentwithgeneralizedabdominalpainandperitonitis.ACTscan
will show a variable quantity and distribution of free air and free
fluid. In addition, an inflamed segment of large intestine is seen,
usually the sigmoid colon, and there may still be a recognizable
abscess,either pericolonic or pelvic. Thepatient is usually sick and
may be severely septic. Initial management begins with fluid
resuscitation,broad-spectrumantibiotics,andpaincontrol.
How we manage these patients is then decided based on the
severityoftheirsepticstate.PracticallyspeakingIdefine‘ill’(relatedto
thepatient’s sepsisandcomorbid medical conditions)asthose patients
who are in a monitored setting, requiring pharmacological support for
their blood pressure, and/ordemonstrating another system failure such
as renal or respiratory deterioration. A patient’s comorbid medical
conditions also factor into my classification of ‘ill’. If the patient suffers
from heart failure, is malnourished (albumin <3.0g/dL), or is
immunosuppressed(transplantorchemotherapypatients),Iconsiderhim
tobe athigherrisk. Ageis lessofa factorin my opinion;a 45-year-old
kidneytransplantpatientismoreworrisomethana75-year-oldguythat
runsmarathons.Solet’slookathowwedealwiththeillandnon-ill.
Notveryill
Thesepatientshavepain,peritonealsignsandfeverbuthavenoother
septic sequelae. I have colleagues that will manage these patients
with i.v. antibiotics, bowel rest and — selectively — placement of
oneormorepercutaneousdrainsinlargercollections.Ithinkthisisa
reasonable approach, especially if the CT findings are localized rather
thandiffuse.Ofcourse,suchpatientsmustbecloselywatchedtoensure
thattheydon’tdeteriorate.Iamalsoconvincedthatthismanagement
choice results in prolonged hospital stays. I am, therefore, an
advocate of a diagnostic laparoscopy and peritoneal lavage with
drainage (to be described below).I thinkthepatients recover faster
andhaveminimalmorbidityfromtheprocedure.Thereisnoneedto
resect the colon at this time as long as you don’t identify a
perforation.Again, conservativetreatmentwith antibioticsmayachieve
the same results but in my experience is associated with a longer
morbidityandhospitalstay.
Septicbutnotcritical
Thesepatientsaresicker—tachycardia,fever,pain,tenderness,and
looktobeindistress.Ithinkitisperfectlyreasonabletoapproachthese
patients laparoscopically as well; of course, after optimal resuscitation
and i.v. antibiotics. If they don’t tolerate pneumoperitoneum (which
shouldnothappenifhypovolemiahasbeencorrected)thenconvert
toalaparotomy.Atlaparoscopydoasdescribedbelow…
Criticallyill
These are the patients that are hemodynamically unstable, requiring
pressor support, or in respiratory distress. I don’t mess about with
these patients! After stabilizing them in the ICU, I proceed
immediatelytotheoperatingroom,makealargeincisionandresect
the diverticular segment (if possible), clean the belly out, and
mature an end colostomy. If I can’t resect (rarely) then I drain and
divert.Theirbestchanceforsurvivalisaquick,safeoperationforsource
control combined with the skilled care of a well-trained surgical
intensivist.
HincheyIVpatients
ThisisacomplicationIseeevery2to3years.
Thesearethepatientswithfeculentperitonitis.Pre-operativelyitis
hardtodifferentiatethesepatientsfromthoseweclassifyasHincheyIII,
buttheytendtobe sicker. Atip-offontheCTscanisthefindingof
oralcontrastintheperitonealcavity —if the contrast is there,the
chancesarethats**thasexitedwithit!
Istillfollowtheabovecoursebasedonthepatient’ssepticstatus.But
if I find feculent peritonitis on laparoscopy, I will convert to a
laparotomy and perform a resection and end colostomy — a
Hartmann’s procedure and ‘peritoneal toilet’. Older studies have
relayed a ~30% mortality associated with feculent peritonitis. Newer
studieshavequestionedthis,andsomeevengoontoadvocatetheuse
oflaparoscopiclavagecombinedwithrepairofthecolonperforationwith
drainage—asopposedtoresection.Iamnotcomfortablewithsuchan
approach— I havefound that Ican’tadequately cleantheabdomen of
stoolwiththelaparoscopicsuctionirrigatorandthatthecolonicwallina
patient with perforated diverticulitis and feculent peritonitis never holds
sutures. So Ibeseech you: ifyou see stool,don’t f…, sorry, muck
about.MakeanincisionandgetonwithitandgetthemtotheICU.
Theoperations
Whether performing a laparoscopic procedure or an open
resection,theprinciplesforoperatingonacutediverticulitisarethe
same.Hereareafewrulestoliveby:
•
Alwaysinitiatedissectionawayfromtheareaofinflammation.Don’t
gonearthephlegmonuntilyouhaveidentifiedkeystructures.
•
Afterinitiatingthedissectioninacleanplane,locatetheureter.
•
After finding the ureter,always ensure itis lateral toyour plane of
dissection. Be cognizant of the iliac and gonadal vessels, but
above the sacralpromontory, as long asthe ureter isin view
andlateraltowhereyouareworking,youshouldnotinjurethe
othertwo.
•
Less is morewhen patients are sick. So If the patient is septic
and not doing well, perform a proximal diversion, clean out and
drain,andcomebacktofightanotherday.
Laparoscopiclavage,drainage(andpossibleresection)
Iperformthese operationswiththe patientinthe modifiedlithotomy
position.Youneverknowwhatyouwillfindandifyoustartinthesupine
positionyouwillmost assuredlywishyouhadaccesstothe anus(it’sa
colorectalsurgeonthing…).Tuckbotharmswithpaddingandsecurethe
patient to the table — to adequately examine and lavage these
patientsyouoftenneedtotilttotheextremeleftandrightandplace
inasteepTrendelenburgposition.
Iplaceanumbilicalportfirst(Hasson)andlookforfeces;ifIsee
(andsmell)it,IamdonewiththelaparoscopeandImakeamidline
incision.IfIfindpus,Iwillplacetwoother5mmtrocars—arightlower
quadrantandasuprapubicone.Thisisoftenallthatisneededtoperform
thelavageandexaminationofthecolon.Ifneeded,Iwilladdaleftlower
quadranttrocar.
InitiallyIexaminetheinflamedcolon. Usuallyyouseeaperforated
abscess cavity and no opening to the colon. Sometimes you see no
cavityandjusttheinflamedbowel.Ifyoudon’tseeanobviousholein
the colon, for God’s sake do not go poking for it! In other words
don’tmobilizethecolonunlessyouplanonresectingit.Mostofthe
timeyoujustseetheinflamedcolonwithapartoftheabscesscavity;in
thesecasesIirrigate the abdomen — all four quadrants and the pelvis
until clean and then leave a closed suction drain (I love the fat round
Blake drain, Danny prefers the slender 7mm Jackson-Pratt...) in the
abscesscavity ornearthe colon,bringing it outthrough thesuprapubic
trocarsite.Thepurposeofthisdrainisnottodrainthegeneralperitoneal
cavity,whichisa‘missionimpossible’,buttodrainanycolonicholewhich
wemayhavemissed.Thetruth,however,isthatwealmostneversee
anyfecesfromsuchdrainsafterlaplavage forpurulentperitonitis
—thereasonbeingthattheperforationsinsuchcasesareminute
andself-sealingrapidly;thisiswhylaplavageissuccessful…
In the rare case when I see the colonic perforation I resect the
colon— even in the absenceofvisible feces. I don’t trustthatsutures
will hold ininflamed colon and I hate to leave an open hole within the
abdomen,drainedornot.
In the ‘not-very-ill-patient’ and under optimal conditions I will
attempt the resection laparoscopically rather than convert
immediately. (However,if youare notvery welltrained inelective
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