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4 Diverticulitis: Beyond the Basics
53
Fig. 4.2 Pelvic abscess (Hinchey II) with foci of free air
resolution and do not require percutaneous drainage or repetitive CT scans (especially if the patient is clinically responding with decrease in pain, fever, and leukocytosis) (Fig. 4.2 )
[ 48 ]. Combined series have shown that initial treatment with
antibiotics (with or without percutaneous drainage) is successful in 30–56 % of patients [ 49 ]. Percutaneous drainage
was initially used as a bridge to surgery; patients underwent
drainage, sepsis resolved, and surgery was then performed
electively [ 50 ]. Currently, percutaneous drainage is also used
as defi nitive therapy, and some patients may not have further
symptoms following successful resolution of the abscess.
The decision to perform subsequent resection may therefore
be made on an individual basis, recognizing patients with
abscess have more severe diverticulitis and are more likely
to require surgery. In rare cases, laparoscopic drainage may
be performed if there is no radiologic window to drain an
abscess (Video 4.1 ). The location of the abscess has been
shown to help determine the clinical course, as those patients
with more distant abscesses (i.e., Hinchey stage II) are
more likely to require resection than patients with pericolic
abscess. In a cohort of 465 patients, 73 patients (17 %) had
an abscess, of which 45 patients had a pericolic abscess and
28 patients had a pelvic abscess. A larger number of patients
with pelvic abscess (71 %) required surgery compared to
those with pericolic abscess (51 %) [ 51 ].
Perforated Diverticulitis with Purulent or Feculent Peritonitis
Key Concept : The traditional therapy of mandatory colonic
resection with or without diversion for perforated diverticulitis continues to evolve with the development of improved
imaging , antibiotic success , endoscopic techniques , and
implementation of laparoscopic lavage .
The optimal treatment for perforated diverticulitis and
associated peritonitis continues to evolve. Options include
Hartmann resection, sigmoid resection with primary anastomosis (in selected patients), sigmoid resection and primary
anastomosis with proximal diversion, on-table lavage with
primary anastomosis, and laparoscopic lavage without resection. Hartmann resection remains one of the most common
operations performed for perforated diverticulitis but has a
number of drawbacks. Approximately 30 % of patients never
undergo reversal of the stoma [ 52 , 53 ]. In addition, the oper-
ation has considerable morbidity and a reported mortality of
up to 18.8 % [ 54 ]. Over the years, a number of other options
have been advocated. Fibrin glue with suture repair and
omental patching of the perforation has been reported [ 55 ].
Two studies (both underpowered) looked at the role of
defunctioning the diseased segment with suture of the perforation and proximal diversion versus resection and had different conclusions [ 56 , 57 ]. The role of on-table lavage in
approaching patients with colonic emergencies has largely
fallen out of favor since the need for bowel preparation has
been challenged by a number of reviews [ 58 ]. A systematic
review of 569 cases in 50 studies suggested that primary
anastomosis with or without diversion was “safe in certain
patients with peritonitis” but noted a mortality of 9.9 % and
an anastomotic leak rate of 13.9 % [ 54 ].
In approaching the patient with perforated diverticulitis, it is important to distinguish between patients who have
evidence of peritonitis on physical examination and those
patients who have CT fi ndings consistent with perforation
but no objective fi ndings of toxicity. While many surgeons
trained in the 1970s or 1980s were taught that the fi nding
of free air on a chest x-ray or KUB was an absolute indication for surgery, the fi ndings of free air on CT imaging
do not necessarily translate into similar recommendations.
Dharmarajan and coworkers evaluated CT fi ndings of perforated diverticulitis and devised a grading system based on the
amount and location of abnormal air, which may assist with
clinical decision-making [ 59 ]. While a grading system is a
useful adjunct, I personally rely more heavily on the clinical
status of the patient and base my initial strategy on the physical examination fi ndings more than the CT fi ndings alone.
There has recently been a renewed interest in the role of
laparoscopic lavage without resection for patients with perforated diverticulitis and associated purulent peritonitis. In
1996, O’Sullivan and colleagues reported 8 patients with
perforated diverticulitis and purulent peritonitis who underwent a laparoscopic lavage [ 60 ]. No resection of the sigmoid
colon was performed, and patients were subsequently treated
with intravenous antibiotics. At a follow-up of 12–48 months,
no patient required subsequent resection, and no patient
required an emergent colostomy. Based on these initial
encouraging results, a prospective multi-institutional trial
54
P. L . R ob er ts
was subsequently performed of 100 patients with perforated
diverticulitis who underwent laparoscopic lavage [
61 ]. The
median age was 62.5 years, and patients were followed for
36 months. The procedure was performed with an umbilical,
suprapubic, and right lower quadrant ports, and patients were
lavaged with 4 l of fl uid or lavaged until the returns were
clear. Eight out of the 100 patients were noted to have fecal
peritonitis and were converted to an open procedure and
underwent resection and stoma. Of the 92 patients who were
managed with laparoscopic lavage, no patient required subsequent resection for diverticulitis at a median follow-up of
36 months. There was an overall 4 % morbidity and 3 %
mortality rate for the cohort. Two patients developed a pelvic
abscess and required drainage, while 2 patients presented
with a subsequent attack of diverticulitis. The authors concluded that laparoscopic lavage was a reasonable alternative
with low mortality and low morbidity, particularly when
compared with Hartmann resection. Furthermore, they suggested that elective resection, even in this group of patients
who presented with perforation, was probably unnecessary
and that readmission was uncommon.
Currently, the role of laparoscopic lavage continues to
evolve in the treatment of patients with perforated diverticulitis and associated purulent peritonitis. A number of
additional small series have been reported, including a
recent review article evaluating 12 nonrandomized studies
encompassing 301 patients with a mean age of 57 years [ 62 ].
Although the majority of patients in these combined series
had Hinchey III classifi cation (i.e., purulent peritonitis), 25 %
of patients had Hinchey II disease. In the Myers series, 25 %
of patients also had Hinchey II disease, suggesting that some
of these patients could potentially have been treated with
bowel rest and antibiotics alone, along with subsequent percutaneous drainage for those patients developing abscesses
[ 61 ]. In this combined series, the conversion rate was 4.9 %,
while the mean complication rate was 18.9 % and mortality
was 0.25 %. Subsequent resection was performed in 51 %
of patients, and the majority of the resections were laparoscopic. In the future, we need to identify those patients who
may optimally be treated by lavage. Further classifi cation of
the degree of peritonitis either by the Mannheim peritonitis
index or the peritonitis severity score may help to further
defi ne the optimal candidate for lavage. Similarly, the need
for subsequent resection has not been defi ned. In the Afshar
series, the majority of patients who underwent elective
resection did so because of surgeon preference [ 62 ]. It goes
without saying that colonoscopic evaluation of the colon is
important in patients to exclude a diagnosis of perforated
colon cancer.
A number of guidelines have been refi ned to include a statement on lavage. The European Association for Endoscopic
Surgery consensus statement of laparoscopy for abdominal
emergencies states that “colon resection remains the gold
standard, but laparoscopic lavage and drainage may be considered in some selected patients” [ 16 ]. The Association of
Coloproctology of Great Britain and Ireland states that “laparoscopic lavage may play a role in some patients with acute
diverticulitis. Whilst this is an alternative to resection in the
acute setting for some patients, it is not certain whether it is
an acute alternative to delayed resection” [ 12 ]. At the present
time, I use laparoscopic lavage selectively in otherwise fi t
patients with perforated diverticulitis. In the concept of the
calculated risk, we as the surgeons “make the calculations,”
and the patients “incur the potential risk.” I do not generally
recommend lavage to unstable patients or those with a number of other associated comorbidities.
Reoperative Surgery for Diverticular Disease
Key Concept : Reoperative surgery entails unique technical
and decision - making challenges that need to be considered
both prior to and at the time of surgery to optimize
outcomes .
Reoperation for complicated diverticular disease occurs
for two main reasons: as a planned procedure to restore intestinal continuity after resection, stoma, and Hartmann closure
of the rectum and as an unplanned procedure to treat complications or unanticipated events after initial resection and
primary anastomosis. The latter occurrence is mainly due
to anastomotic leakage but may occur from fi stula, abscess,
or stricture at the anastomosis. This section discusses
considerations prior to reoperative surgery including anatomy, timing of reoperation, anatomic considerations, preoperative preparation, conduct of the operation, and outcome.
Reoperative Surgery After Hartmann Resection
The Hartmann resection was fi rst described by Henri
Hartmann for the treatment of rectal cancer in which he
described two patients presenting with obstruction in whom
he resected the tumor and closed the “superior part of the
rectum and left it in the peritoneum without disturbing the
pelvic fl oor” [ 63 ]. The procedure quickly became the proce-
dure of choice for the majority of patients who underwent
emergency surgery for perforated diverticulitis in the second
half of the twentieth century, replacing the three-stage procedure of initial colostomy, subsequent resection, and fi nally
colostomy takedown that was advocated by LockhartMummery [ 64 , 65 ]. Of note, Hartmann believed that reversal
of the Hartmann procedure should not be attempted.
Currently, Hartmann takedown still has signifi cant morbidity
and mortality and a relatively low reversal rate. Unfortunately,
the risk of needing to return to the operating room for a
repeat stoma remains high.
4 Diverticulitis: Beyond the Basics
55
Timing
After Hartmann resection for perforated diverticulitis, most
patients are eager to proceed as soon as possible with reversal of the colostomy. In contrast to patients who may be
chronically ill with infl ammatory bowel disease for years
prior to resection, these patients often had never been ill
before and had never anticipated leaving the hospital with a
stoma after treatment for diverticulitis. Surgery for Hartmann
reversal may be undertaken early (<3 months from initial
surgery) or late (>3 months from initial surgery). There are
advocates of each approach [
66 – 70 ]. Proceeding with
Hartmann takedown close to the time of initial surgery has
several disadvantages, predominantly due to adhesions and
the acute infl ammatory response after initial surgery which
may lead to a diffi cult dissection, potential enterotomies, and
diffi culty with identifi cation of the Hartmann stump. While
waiting for at least 3 months will presumably allow the
patient suffi cient time to heal and facilitate identifi cation of
the Hartmann stump, waiting longer may make identifi cation
of the stump more diffi cult secondary to fi brosis. The two
approaches (waiting less than 3 months vs. greater than 3
months) have not been assessed in a randomized trial. My
approach has been to wait for 3 months prior to Hartmann
takedown. Waiting for this time period ideally reduces the
diffi culty and potential complications from adhesions.
Preoperative Preparation
General preoperative assessment of the patient should
routinely be performed. Nutritional status is optimized.
Cardiopulmonary disease is identifi ed and evaluated.
Reoperative pelvic surgery is associated with a high risk
of thromboembolic complications, and patients are administered appropriate prophylaxis. Although increasing evidence suggests that mechanical bowel preparation is not
necessary, I believe that it is preferable in reoperative surgery to minimize spillage in case the bowel is entered.
Preoperative intravenous antibiotics are administered,
although there is little evidence to support additional
dosing.
Preoperative Imaging
For patients >50 years old who have not had prior colonic
evaluation, a colonoscopy or barium enema should be performed. Prior to planning Hartmann takedown, my preference is to perform a barium enema through the stoma and a
Gastrografi n enema through the rectum. The Gastrografi n
enema is particularly useful as it gives an assessment of the
length and confi guration of the rectal segment and gives an
assessment of any residual sigmoid colon and/or diverticula
4.3 ). Many patients have undergone the initial resec-
(Fig.
tion by another surgeon; at times, because of intraoperative
factors, a substantial amount of sigmoid colon is left in
place. The road map of the specifi c anatomy is better deter-
Fig. 4.3 Gastrografi n enema shows residual sigmoid colon and
diverticula
mined by a Gastrografi n study than by a fl exible sigmoidoscopy, although both can be performed. These procedures are
also helpful to evacuate retained fecal residue. Scybala
retained in the rectum from the original Hartmann resection
should be evacuated at this time or with distal rectal washout at the time of surgery to facilitate placement of a sizer
and subsequently the EEA stapler. Even with a washout at
the time of colostomy takedown, this may be diffi cult to
accomplish.
Intraoperative Considerations
Patient Positioning
Anticipate a long procedure and pad the patient’s bony prominences accordingly. The patient may be placed in lithotomy
position in Lloyd Davies, Allen, or Yellowfi n stirrups. Care
should be taken to avoid pressure on the peroneal nerves
and the hips. Overall, my preferred position is aimed to have
symmetric hip extension, knee fl exion, and thigh abduction.
Extreme hip extension beyond 60° can occasionally lead to
femoral nerve palsies if a self-retaining retractor is positioned
against the extended extremity. The perineum should be hanging slightly over the table to ensure easy passage of the EEA
stapler. Rectal washout can be performed and a mushroom
catheter left in the rectum if desired to facilitate identifi cation of the Hartmann pouch. A proctoscope and/or sizer may
also be used intraoperatively to identify the pouch. The vagina
should also be included in the prep. Alternatively, my preference is to position the patient supine on a split leg table with the
legs abducted. The split leg table avoids potential diffi culties
56
P. L . R ob er ts
with long-standing lithotomy position including nerve injuries
and compartment syndrome. Once again, care must be taken
to ensure that the patient is positioned far enough down on
the table that access to the anus (to pass the EEA stapler) can
be achieved. A beanbag with the arms tucked at the sides can
be helpful to ensure the patient does not slip cephalad on the
table, especially when in steep Trendelenburg position.
Approach to the Procedure
The procedure may be undertaken by a laparoscopic or open
approach. Adhesions encountered from previous surgery or
prior infection may make a laparoscopic approach impossible. The extent and degree of adhesions may be diffi cult to
predict; on occasion much less severe adhesions are encountered than anticipated, and the procedure progresses quite
smoothly. Alternatively, with extensive adhesions, bowel
injury may occur when attempting to enter the peritoneal
cavity. A reasonable approach is the use of a “peek port”
which entails entering the abdomen through a small incision
and assessing the degree of adhesions [ 71 ]. The laparoscopic
equipment is not opened until the feasibility of a laparoscopic hand-assisted approach is determined. Alternatively, a
port can also be placed away from the site of the previous
surgery to assess the degree of adhesions and the feasibility
of a straight laparoscopic approach.
Exposure and Lighting
The importance of having adequate exposure and lighting
cannot be overestimated with reoperative surgery. If an open
approach is used, the incision should extend to the symphysis
pubis. Cephalad extension of the midline incision may be
needed if splenic fl exure mobilization is needed. Operating
between the patient’s legs provides optimal visualization of
the splenic fl exure as does rotation of the table to a left-side up position.
Adequate OR lighting, a headlight, and/or lighted pelvic
retractors are helpful. A self-retaining retractor with bladder
blade is also used. Straight blade (Wylie renal vein or St.
Mark’s) and curved (Deaver) retractors are available, with
the former being more helpful for deep pelvic dissection,
which is on occasion necessary to free up the Hartmann
stump. Care must be taken to avoid placing these retractors
on the drapes and causing a fi re.
Initial Dissection
The initial dissection is focused on lysing all small bowel
adhesions in the pelvis to be able to identify the Hartmann
pouch. Ultimately, in the majority of cases, all small bowel
adhesions from the ligament of Treitz to the ileocecal valve
are lysed to be able to mobilize the colostomy and bring the
proximal colon down to the pelvis without tension. The pelvic dissection associated with a prior Hartmann resection
may be challenging secondary to dense adhesions and the
inability to distinguish a plane suitable for dissection. It is
advisable to lyse the fi lmy small bowel adhesions fi rst and
then attack the more diffi cult adhesions. With few exceptions, there are small bowel and/or omental adhesions to the
top of the Hartmann pouch. Dense adhesions often occur to
the top of the Hartmann pouch, and encountering staple
material is an indication of proximity to this structure. If
extremely dense adhesions are encountered, hydrodissection
or infi ltration of the fused area with saline with a smallgauge needle may be helpful [ 72 ]. The appendix can also be
drawn down into the pelvis toward the Hartmann and may
occasionally lead the surgeon to believe he or she has
encountered the right ureter. The left ovary and tube, in particular, may be fused with the top of the Hartmann pouch.
Bleeding from the pelvic wall may often occur from entering
the fallopian tubes or a branch of the ovarian vessels.
The ureters should be identifi ed, and the surgeon should
be aware that they may be in an unanticipated position, particularly drawn in more medially, after prior surgery. Ureteral
stents may be used in selected cases with prior severe pelvic
sepsis or unclear anatomy. Stents do not prevent ureteral
injury but facilitate the recognition of such injury. I selectively use stents in patients with hydronephrosis or a large
amount of retroperitoneal infl ammation. The vagina may be
adherent to the rectum and dissection facilitated by placing a
fi nger in the vagina to identify the proper planes.
The colostomy is mobilized by incising the mucocutaneous junction and trying to preserve all the mesenteric attachments. Injection with saline or local anesthetic around the
mucocutaneous junction circumferentially may facilitate
dissection. The stoma is resected and fresh bowel used for
the intended anastomosis. Once the stoma is mobilized, the
surgeon can generally assess whether there is adequate
length for a tension-free anastomosis. Additional length is
facilitated by a number of maneuvers including division of
the lateral colonic attachments, takedown of the splenic fl exure, division of the inferior mesenteric artery at the takeoff of
the aorta, and division of the inferior mesenteric vein at the
inferior border of the pancreas. Alternatively, further length
can be achieved by mobilizing the rectum further distally
and essentially bringing the Hartmann pouch up to the proximal bowel. Once complete mobilization of the proximal
colon is performed and adhesiolysis is completed, the small
bowel and colon can be packed into the upper abdomen.
Identifi cation and Mobilization of the Hartmann Pouch
Once the small bowel is mobilized, the top of the Hartmann
pouch can be identifi ed. Some surgeons mark the top of the
pouch with long suture material to facilitate identifi cation. I
have not found this to be helpful and have found that insertion of a proctoscope or fl exible sigmoidoscope facilitates
identifi cation of the Hartmann pouch. The staple line of the
Hartmann is identifi ed, and the length of the pouch is usually
4 Diverticulitis: Beyond the Basics
57
longer than anticipated, even if it is located below the pelvic
brim. If the staple line is adherent to the presacral fascia, it is
generally safe to commence the dissection in the posterior
midline, thus avoiding the ureters and the iliac vessels. It is
not uncommon for the superior rectal artery to be left intact,
and placing a Babcock clamp on the end of the Hartmann
pouch and applying cephalad traction facilitate identifi cation
of the mesentery and straightening of the rectum. My practice is to mobilize and dissect out the Hartmann pouch at
least to the mid- to proximal rectum. This is generally necessary to “straighten out the rectum,” which often times has a
concertina-like confi guration following Hartmann resection.
If this is not done, it is often diffi cult to guide the EEA stapler
per anum to the top of the Hartmann pouch. Once the
Hartmann pouch is mobilized, a small sizer is placed per rectum to ensure that this passes easily to the area of the intended
anastomosis. In those patients who have had signifi cant sepsis or in those who have had a long-standing Hartmann
pouch, further mobilization may be needed. We have found
that in women further dissection is often needed in the anterior cul-de-sac as the mid-rectum tends to angulate and
adhere to the uterus. Despite further mobilization, some
patients may still have a fairly fi brotic pelvis (in which the
rectum is intrinsically normal but the surrounding tissues are
fi brotic enough that it is impossible to pass a sizer). In this
case, an EEA-stapled anastomosis may not be feasible and a
handsewn anastomosis preferable. The top of the intended
site of anastomosis is then re-resected and the integrity of the
rectum tested by fi lling the pelvis with saline and insuffl ating
the Hartmann pouch.
Performing the Anastomosis
I prefer using the EEA stapler to perform anastomosis after
Hartmann resection. The anvil is placed in the proximal
bowel. A handsewn purse string is placed, or a purse-string
device may be used. A sizer is used to guide through the
rectum to the top of the re-resected Hartmann pouch.
Occasionally, it is diffi cult to introduce the stapler into the
anus, and Khoury and Opelka have reported placement of a
Faensler or Chelsea-Eaton anoscope with gradual dilatation of the sphincter and placement of the stapler shaft
through the anoscope [ 73 ]. The EEA stapler is guided
through with the trocar exiting at the top of the Hartmann
pouch, the anvil is snugged up and secured, and the stapler
is fi red. The instrument is generally removed easily, and
the tissue rings are inspected for thickness and integrity.
The anastomosis is then tested by occluding the bowel
proximally and introducing air through a proctoscope or a
fl exible sigmoidoscope [ 74 ].
Alternatives
There is no one single technique to perform an anastomosis
after Hartmann takedown, and some ingenuity and employ-
ing other techniques may be necessary. The stapler may not
pass up to the top of the rectum because of fi brosis and contraction, particularly if the patient has been diverted for
many years. In this case, there are several alternatives. One
option is to perform a handsewn anastomosis. Another
option is to introduce the stapler and bring the trocar through
the anterior rectal wall, thus performing an end of colon to
side of rectum anastomosis [ 73 ]. Further options include
employing a double purse-string technique in which a purse
string is placed in the proximal colon and the distal end (rectum). The stapler is still introduced through the anus. A fi nal
technique employs a single purse string in the rectum and
placing the stapler through the side of the proximal colon
and completing the anastomosis by transecting the end of the
colon with a TA stapler.
Abdominal Wall Closure
Following completion of the anastomosis, the abdomen is
irrigated and the incision closed. A mass closure technique is
superior to layered closure. A continuous abdominal wall
closure is associated with a lower risk of abdominal wound
dehiscence. Furthermore, a meta-analysis of six randomized
controlled trials found that the risk of incisional hernia formation was signifi cantly less with a continuous compared
with an interrupted closure (regardless of the suture type
used) [ 75 ]. The use of resorbable versus non-resorbable
sutures results in no difference in dehiscence rates, but higher
rates of persistent sinus formation and chronic wound problems occurred with non-resorbable sutures. Optimal primary
wound closure is with a mass closure continuous technique
with resorbable sutures placed at an interval of 1 cm apart
and 1 cm back on the fascia [ 76 ]. Laparoscopic techniques
minimize incision length and wound trauma and may be
associated with less wound complications.
Reoperation for Sepsis and Anastomotic Complications After Hartmann Takedown
Key Concept : Identifi cation of anastomotic leak through testing is an integral part of left - sided anastomosis . For those
experiencing a leak requiring operative intervention , deciding between proximal diversion alone and resection and
diversion depends on the patient ’ s clinical manifestations
and the intraoperative fi ndings .
Anastomotic leak is among the most serious potential
complications after Hartmann takedown (Fig.
4.4 ). The lack
of a standardized defi nition precludes comparison among
units and even a precise incidence of this complication. We
have used the United Kingdom (UK) working party defi nition of leakage of gastrointestinal contents or contrast from a
surgically constructed anastomosis [
77 ]. In our unit, we have
reviewed 998 left-sided colorectal anastomoses and have
noted a clinical leak rate of 4.8 % [
74 ]. Air leak testing was
performed intraoperatively in 825 left colon anastomoses.
58
P. L . R ob er ts
Fig. 4.4 Gastrografi n enema shows a leak at the top of the Hartmann
pouch with extravasation ( arrow ) and intraluminal contrast ( arrow ) into
small bowel
A clinical leak was noted in 7.7 % of anastomosis with a
positive air leak test compared with 3.8 % of anastomosis
with a negative air leak test and 8.1 % of all untested anastomoses ( P < 0.3). The data suggest that air leak testing should
be performed in all such anastomosis to allow the surgeon to
detect and repair a leak at the time of initial procedure.
Management of anastomotic leak depends on the clinical manifestations of the leak and the overall condition of
the patient. Anastomotic dehiscence may manifest as peritonitis, a colocutaneous fi stula, an associated abscess, or
even be relatively asymptomatic. For those patients with
generalized peritonitis, urgent exploration is performed
after fl uid resuscitation and intravenous antibiotics. Stoma
site marking is ideally done preoperatively. Placement in
lithotomy position or on a split leg table is helpful in case
sigmoidoscopy is needed. The two main intraoperative considerations are to leave the anastomosis in place and to
divert proximally or to resect the anastomosis and perform
a colostomy. In patients with total anastomotic dehiscence,
a large defect, or concerns about the viability of the anastomosis, resection of the anastomosis is advisable. The distal
end is stapled or handsewn, and the proximal colon brought
out as a colostomy. Unfortunately, a substantial number of
these patients will never undergo colostomy closure.
In selected cases of a small defect and a relatively stable
patient, the anastomosis may be left in place and diverted
proximally with either a colostomy or ileostomy. A recent
meta-analysis suggested that an ileostomy was associated
with less stoma-related complications and a lower incidence
of abdominal wall hernias [
78 ]. A concern of such an
approach is leaving a large column of stool, which may then
leak through the anastomosis resulting in ongoing pelvic
sepsis. If a diverting ileostomy is performed, lavaging the
distal bowel or endoscopically evacuating the distal bowel
should be considered. An ileostomy may be associated with
a high incidence of dehydration and the need for readmission, especially in elderly patients [
79 ].
Chronic sepsis or anastomotic leak may also manifest as
a colocutaneous fi stula. A major risk factor for the development of a colocutaneous fi stula is the anastomosis to the
distal sigmoid colon and not the proximal rectum [ 45 ]. While
selected cases may heal with good nutritional support and a
tincture of time, re-resection of the anastomosis is needed for
persistent fi stulas.
Reoperation for Recurrent Diverticulitis
Key Concept : Re - resection of the prior anastomosis with
special attention to the distal and proximal margins , along
with ensuring a tension - free anastomosis , is paramount to
improving outcomes for reoperative diverticular disease .
Recurrent diverticulitis following sigmoid resection is
uncommon. In the patient presenting with abdominal pain
following resection for diverticulitis, a thorough investigation should be undertaken to exclude other causes of abdominal pain including infl ammatory bowel disease, irritable
bowel syndrome, gynecologic disease, adhesive disease, and
infectious complications from the initial resection. Recurrent
diverticulitis should also be distinguished from poorly characterized pain following resection. A recent study of 325
patients who underwent either laparoscopic or open sigmoid
resection for diverticulitis noted that 20 % of patients had
ongoing functional symptoms [ 80 ]. Munson and colleagues
found that 27.2 % of patients following resection for diverticular disease continued to have pain [ 81 ]. The most com-
mon risk factor associated with recurrent diverticulitis is
failure to perform a colorectal anastomosis and performing a
colocolic anastomosis with retained distal sigmoid colon as
the proximal section margin (Fig. 4.3 ). Although diverticuli-
tis may only involve a portion of the sigmoid colon, it is
important to resect the sigmoid colon and perform resection
to the proximal rectum. The rectum is identifi ed at the level
at which the tenia fan out, which is usually at the sacral
promontory. In the presence of prior infl ammation, this spot
may not be readily apparent, in which case the level of the
bowel just below the sacral promontory is a reasonable landmark. The proximal resection margin is less well established.
While it is not necessary to resect all proximal diverticula,
the anastomosis should be performed in soft pliable bowel.
In the evaluation of the patient with recurrent diverticulitis, it
is helpful to obtain prior records, including the pathology
report and operative note, to ensure that the diagnosis was
indeed diverticulitis and to review specifi c operative details.
4 Diverticulitis: Beyond the Basics
59
Ureteral stents may be considered especially if the original
operation was diffi cult, associated with unclear anatomy, or
associated with postoperative pelvic sepsis or anastomotic
complications. The patient should be prepared for the possibility of a temporary stoma, especially if the anastomosis is
low. Adequate mobilization of the colon is key, and splenic
fl exure mobilization is necessary. If these various maneuvers
do not result in suffi cient mobility and allow a tension-free
anastomosis, the middle colic vessels on occasion require
division with blood supply of the residual colon based on the
right and/or ileocolic vessels. Additional approaches such as
bringing the right colon through a window in the mesentery
or resecting further and bringing the hepatic fl exure down to
the rectum may be needed [
82 , 83 ].
The prior anastomosis may also be densely adherent to
the presacral fascia. The presacral fascia is a condensation
of the parietal endopelvic fascia, and it is important to get
into the right plane; otherwise, massive pelvic bleeding
may occur from the avalvular presacral veins which communicate with the basivertebral veins [ 84 ]. The sympa-
thetic pelvic nerves run caudad and lateral over the
presacral fascia to join the pelvic plexus laterally and are at
risk for damage if the plane is not developed and exposed
correctly. Depending on the diffi culty of the pelvic dissec-
be necessary.
Reoperative surgery, in general, is challenging, and reoperative surgery for diverticulitis, specifi cally, is no exception. No one approach can be employed to guarantee success,
and the surgeon must have a number of approaches and techniques in his or her armamentarium to ensure optimal patient
outcome.
Conclusion
Our understanding and treatment of diverticulitis con-
tinue to evolve. Recent trends have shown increased use
of laparoscopic techniques both for elective and emer-
gency surgeries and a trend to primary anastomosis
for both elective and urgent operations [ 85 ]. Although
the literature supports a more conservative approach to
patients with uncomplicated diverticulitis, there has been
a dramatic increase in the frequency of elective surgi-
cal resection for diverticulitis by 38 %. The increase
in elective surgical resection is nine times greater
than the increase in urgent surgical resection, suggest-
ing that clinical practice does not mirror the current
recommendations.
Future investigations should focus on the identifying
risk factors for recurrent diverticulitis and optimally identify those patients who require early surgical intervention.
Ultimately increased understanding of this common disease will help physicians and surgeons in the prevention
and treatment of diverticulitis.
Summary Pearls
Diverticulitis is one of the most common gastrointestinal diseases. The trend over the last decade has been toward a greater
understanding of the disease that will ultimately result in a
more “personalized” approach to the patient. I believe that we
will ultimately be able to delineate the natural history of diverticular disease and predict the clinical course of disease for an
individual patient. In the meantime, you should have a thorough understanding of all the factors involved when deciding
on a management strategy to ensure optimal outcomes.
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Carcinomatosis: Cytoreduction and Heated Intraperitoneal Chemotherapy (HIPEC) Versus Palliation
Björn L. D. M. Brücher , Avital Itzhak , Anton Bilchik ,
Aviram Nissan , and Alexander Stojadinovic
5
Abbreviations
BMI Body mass index
CC score Completeness of cytoreduction score
CDSS Clinical decision support systems
CRC Colorectal cancer
CRS Cytoreductive surgery
CT Computed tomography
CTR-1 Copper transport protein-1
B. L. D. M. Brücher , MD, PhD, FRCS (Engl), FACS (*)
Department of Surgery , Bon Secours Cancer Institute ,
Richmond , VA , USA
INCORE = International Consortium of Research of the TheodorBillroth- Academy
e-mail: b-bruecher@gmx.de
A. Itzhak , MD, FACS
Department of Surgery , Bon Secours Cancer Institute ,
Richmond , VA , USA
Uniformed Services University of the Health
Sciences , Bethesda , MD , USA
A. Bilchik , MD, PhD, FACS
Department of Surgery , John Wayne Cancer
Institute , Santa Monica , CA , USA
A. Nissan , MD, FACS
Department of Surgery , Hadassah-Hebrew University ,
Jerusalem , Israel
United States Military Cancer Institute , Bethesda , MD , USA
A. Stojadinovic , MD, FACS
Department of Surgery , Bon Secours Cancer Institute ,
Richmond , VA , USA
Uniformed Services University of the Health
Sciences , Bethesda , MD , USA
United States Military Cancer Institute , Bethesda , MD , USA
®
, Richmond , VA , Germany-Israel-Serbia-USA
DPAM Disseminated peritoneal adenomucinosis
EPIC Early postoperative IP chemotherapy
HIPEC Hyperthermic intraperitoneal Chemotherapy
ICU Intensive care unit
IV Intravenous
NCCTG North Central Cancer Treatment Group
OR Operating room
PC Peritoneal carcinomatosis
PCI Peritoneal cancer index
PSM Peritoneal surface malignancy
QOL Quality of life
RCT Randomized controlled trial
TPN Total parenteral nutrition
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