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18. Benign Colon: Diverticular Disease 399
organisms cultured from acute diverticular abscess and peritonitis include the aerobic and facultative bacteria Escherichia
coli and Streptococcus spp. The most frequently isolated
anaerobes include Bacteroides spp. ( B. fragilis group), Pepto-
streptococcus , Clostridium , and Fusobacterium spp.
• Signs of more advanced disease including marked leukocytosis,
high fever, tachycardia, or hypotension as well as a physical
examination demonstrating more advanced intraabdominal
pathology, dictate a need for inpatient management.
• Patients admitted for inpatient care will usually undergo a
baseline CT scan which can confi rm the diagnosis, rule out
potential alternative diagnoses, and evaluate for complicated
disease that would require a change in initial management.
• Antibiotics should be administered via an intravenous route.
Generally the patient will be placed NPO (nothing by mouth)
until there is evidence that clinical progress is being made and
surgery will not be necessary.
• The diet is then gradually advanced from clear liquids and then
to low residue for a variable period of time before reinstituting
a high fi ber diet.
• Symptoms should improve within 24–72 h. Failure to improve
should prompt further diagnostic workup including repeat CT
scan and reevaluation of the need for alternative interventions
such as operation or abscess drainage.
• Worsening of the patient’s clinical condition, particularly
progression to generalized peritonitis, should prompt urgent
operative management.
Surgical Management
• The goal should always be to manage a complex patient in a
way that will maximize the opportunity to avoid emergency
surgery in favor of an elective resection.
• Surgical options include primary resection with anastomosis
with or without proximal diversion, resection with proximal
colostomy, and oversewing of the rectal remnant (Hartmann’s
procedure) or mucous fi stula (Mikulicz operation), simple
diversion with drainage of the affected segment, diversion with
oversewing of the perforation site, and, rarely, subtotal colectomy.
Adjunctive measures include on-table lavage and the option of
a laparoscopic approach.
400 The ASCRS Manual of Colon and Rectal Surgery
• For the most part, today’s discussions revolve around the relative merits of a one-stage versus a two-stage approach in acute
cases requiring urgent or emergent surgery. The three-stage
approach is unlikely to be used except in the most extreme cases
of medical instability.
Intraabdominal Abscess
• For a patient found to have an abscess, there is signifi cant
clinical evidence supporting the advantages of percutaneous
drainage and the conversion of an emergent operation with
its attendant increased morbidity and mortality to the relative
safety of elective operation.
• An abscess not responding to medical management should be
drained percutaneously or transrectally as appropriate to its
location (Fig. 18.2 ).
• If drainage cannot be accomplished nonoperatively or if
drainage is performed but fails to resolve systemic signs and
symptoms, operation is indicated.
• Generally, the clinical scenario in this situation would be that
of an advanced Hinchey class II. Although it is possible that
intraoperative fi ndings would support a resection with primary
anastomosis with or without proximal diversion, it is more
likely that a Hartmann’s resection will be required.
Indications for Surgery for Acute Disease
• The indications for surgery of acute disease include:
failure to respond to nonoperative management including
a persistent phlegmon, failure of percutaneous or transrectal
drainage of an abscess or increasing fever, leukocytosis,
tachycardia, hypotension, signs of sepsis, or a worsening
physical examination;
free perforation with peritonitis;
obstruction that does not resolve with conservative therapy.
• Perforation without peritonitis may not require operation
(Fig. 18.3 ).
Surgical Procedures
• For acute disease, the choice of operation is highly dependent
on the degree of infl ammatory response encountered at the
time of operation. Because most acute disease can be managed
18. Benign Colon: Diverticular Disease 401
a
b
Fig. 18.2. ( a ) A centrally located pelvic diverticular abscess. ( b ) The same
abscess after CT-guided percutaneous drainage.
nonoperatively (including the percutaneous drainage of most
abscesses), the fact that an operation has become necessary
suggests rather advanced pathology and the need to be conservative.
• In general , most Hinchey class I and some class II disease
can be managed with a one-stage procedure (resection and
402 The ASCRS Manual of Colon and Rectal Surgery
Fig. 18.3. This CT scan shows a small pneumoperitoneum anteriorly. There was
not physical evidence of peritonitis. This patient was managed nonoperatively
with intravenous antibiotics.
anastomosis) if the patient is stable, the extent of contamination is limited, and adequate bowel preparation is possible,
recognizing, however, that the necessity of mechanical bowel
preparation in elective colon resections has been recently questioned. Proximal diversion may be appropriate.
• Most cases of Hinchey class III and IV disease will require a
two-stage approach.
• A major disadvantage of a two-stage procedure is that 35–45%
of patients never have their colostomy closed. Women are more
likely than men to not have closure.
• In patients with preexisting incontinence, a Hartman’s pouch
should be the procedure of choice.
• For patients who do not undergo closure of their stoma, it is
critical that their rectal stump undergo scheduled surveillance
for neoplasia as the remaining rectum has the same risk for
neoplasia as the remainder of the colon.
18. Benign Colon: Diverticular Disease 403
Complications
• Predictors of complications from resection for diverticular disease include advanced age (older than 70–75 years), two or
more comorbid conditions, obstipation at initial examination,
the use of steroids, sepsis, obesity, and emergent rather than
elective resection.
• Complications of resection include anastomotic leak and hemorrhage. The prevalence of leak from a low intraperitoneal
anastomosis is generally considered to be between 2 and 5%.
Such leaks can lead to localized or systemic sepsis without
an abscess, an abscess with or without sepsis, peritonitis, and
stricture.
• The diagnosis is dependent on a high index of suspicion on the
part of the surgeon and quick response to any unusual signs
of sepsis. Fever, vague abdominal pain, diarrhea, obstructive
symptoms, oliguria, prolonged postoperative ileus, and sepsis
all should raise the concern of a leak.
• The diagnosis is usually confi rmed by water-soluble contrast
enema and/or CT scan with intravenous, oral, and rectal contrast.
• A contained leak without an abscess can usually be managed
with intravenous antibiotics and close observation.
• Free extravasation of contrast, failure to respond to treatment
within 24–48 h, or initial severe sepsis or peritonitis requires
exploration with resection of the anastomosis and proximal
diversion.
• Repair of the anastomosis with proximal diversion is usually
unsatisfactory because of the high risk for recurrent leak in this
infl ammatory setting.
• A leak that results in an abscess can generally be managed with
percutaneous or transrectal drainage.
• A colocutaneous fi stula related to a diverticular resection will
usually respond to nonoperative measures. Provided that there
is no distal obstruction or foreign body and that Crohn’s was
not the cause of the original symptoms, spontaneous closure
should be anticipated.
– Important steps to take to facilitate this closure include
drainage of any undrained abscess, attention to nutritional needs, and appropriate wound care.
• Stricture is an unusual complication related to diverticular
resections unless the underlying process is Crohn’s disease.
404 The ASCRS Manual of Colon and Rectal Surgery
In the rare instance when stricture does occur, the likely etiologies include ischemia or localized sepsis caused by confi ned
leak. Such strictures can usually be managed by dilatation with
a hydrostatic balloon or rigid proctoscopy but occasionally will
require a formal restapling or resection.
• Ureteral injuries are reported to occur in 1–10% of abdominal
surgeries. Early identifi cation of any injury is the key to preventing signifi cant morbidity.
– Although ureteral stents have not been shown to decrease
the rate of injury, they do improve intraoperative identifi cation of the ureters and the early identifi cation of any
ureteral injury.
– The decision to place ureteral stents before operation
should be a function of clinical suspicion and the extent
of retroperitoneal infl ammation on CT scan.
Indications for Surgery for Recurring and Chronic Disease
• Patients with multiple, recurrent episodes of acute diverticulitis
documented by CT scan should be considered for resection.
• Patients with complicated diverticulitis should be considered
for resection after one attack.
• The ultimate goal is to perform an operation electively rather
than as an emergency.
• It is now doubtful that age itself should be a primary consideration in the decision to operate. The literature is mixed with proponents of a more aggressive approach to the disease in young
patients and those that believe age alone does not signifi cantly
increase risk.
• CT evidence of complicated or “severe” disease has been one
of those criteria that have shown some promise in predicting
risk. Abscess, extraluminal air, and extraluminal contrast have
been associated with an increased risk of poor outcome from
medical management regardless of age.
• Another approach is to identify specifi c groups of patients
(other than age) who are at increased risk. Immunocompromised patients are one group that is at particular risk for poor
outcome. The risk is attributable to a higher incidence of free
perforation and more severe infl ammatory complications when
perforation does occur.
• Patients with autosomal dominant polycystic kidney disease
undergoing renal transplant are a very high risk group.
18. Benign Colon: Diverticular Disease 405
Prophylactic resection in such patients with a history of any
diverticulitis is recommended.
• Recent data have suggested that the recommendation for resection after two episodes of diverticulitis treated as an inpatient
may result in too many patients undergoing resection thereby
increasing the total cost of health care.
Performing resection after the third episode of diverticu-
litis results in signifi cant cost savings.
Performing resection after four documented episodes
rather than after two results in fewer deaths, fewer colostomies, and additional cost savings of more than $5000
per patient in those younger than 50.
Others question the role of elective resection at all
because of the high success rate of nonoperative management and the large percentage of patients presenting
with urgent surgical disease that have no previous history
of diverticulitis.
Surgical Procedures
• Patients undergoing resection for chronic disease will almost
always be candidates for single-stage resection with primary
anastomosis.
• Additionally, patients returning for closure of a colostomy
after initial diversion and drainage, diversion with oversew of
perforation, or diversion with resection via either Hartmann’s
or a Mikulicz procedure, can all typically be managed with one
additional operation only.
Complications
• The complications related to operation for chronic disease
in many ways parallel those already discussed for acute
disease.
• In addition, a noted complication of operating on chronic
disease is failure to achieve symptomatic relief. This usually
results from a missed diagnosis of Crohn’s disease or IBS. Any
“recurrence” of symptoms after resection for chronic diverticulitis should raise the suspicion of this possibility.
• The presence of functional bowel symptoms preoperatively in
this group of patients has been associated with poorer functional results postoperatively.
406 The ASCRS Manual of Colon and Rectal Surgery
Management of Fistula
• The general principle of management is resection of the colon,
usually with primary anastomosis.
• Treatment of the other involved organ/site varies:
– For the bladder, simple drainage of the bladder with an
indwelling urethral catheter for 5–7 days is advised.
– No treatment of the vagina is required in most circum-
stances.
– Cutaneous fi stulas will usually close by delay or second-
ary intention.
– Enteric fi stulas require repair or resection of the involved
small bowel or colon.
• If there is any question of cancer, an en bloc resection of a portion of the involved organ must accompany the resection.
• Occasionally nonoperative management is appropriate when
symptoms are minor or when the patient is at otherwise too
great a risk for other health reasons.
• The use of long-term suppressive antibiotic therapy in selected
patients with colovesical fi stula has been shown to eliminate
symptoms and prevent complications related to the fi stula until
death from other causes.
Techniques for Appropriate Resection
• The practice parameters of the American Society of Colon
and Rectal Surgeons set out several general recommendations
regarding resection of diverticular disease. For elective resections, all thickened, diseased colon, but not necessarily the
entire proximal diverticula-bearing colon, should be removed.
• All of the sigmoid colon should be removed. When anastomosis is elected, it should be made to normal rectum and must be
free of tension and well vascularized.
• The single most important predictor of recurrence after sigmoid resection for uncomplicated diverticulitis is an anastomosis to the distal sigmoid colon rather than the rectum.
Laparoscopic Surgery
• Higher conversion rates are associated with more complex
disease. Recurrence rates match those for open procedures,
and length of stay is shorter and complications fewer. As data
18. Benign Colon: Diverticular Disease 407
continue to accumulate, it seems that laparoscopic surgery
will have a signifi cant role in the management of diverticular
disease.
Appendix: Practice Parameters for the Treatment
of Sigmoid Diverticulitis
Prepared by The Standards Task Force, The American Society of Colon
and Rectal Surgeons.
The initial evaluation of a new patient with suspected acute diverticulitis should include a problem-specifi c history and physical examination;
a complete blood count, urinalysis, and plain abdominal radiographs
may be useful in selected clinical scenarios. Computerized tomography
scan of the abdomen and pelvis is usually the most appropriate imaging
modality in the assessment of suspected diverticulitis. Contrast enema
x-ray, cystography, ultrasound, and endoscopy are sometimes useful in
the initial evaluation of a patient with suspected acute diverticulitis.
Nonoperative treatment typically includes dietary modifi cation and
oral or intravenous antibiotics. Radiologically guided percutaneous
drainage is usually the most appropriate treatment for patients with a
large diverticular abscess.
After resolution of an initial episode of acute diverticulitis, the colon
should be adequately evaluated to confi rm the diagnosis. Colonoscopy or
contrast enema x-ray (probably with fl exible sigmoidoscopy) is appropriate to exclude other diagnoses, primarily cancer, ischemia, and infl ammatory bowel disease.
Urgent sigmoid colectomy is required for patients with diffuse peritonitis or for those who fail nonoperative management of acute diverticulitis. The decision to recommend elective sigmoid colectomy after
recovery from acute diverticulitis should be made on a case-by-case
basis. Elective colon resection should typically be advised if an episode
of complicated diverticulitis is treated nonoperatively. The resection
should be carried proximally to compliant bowel and extend distally
to the upper rectum. When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients.
Reprinted from Dis Colon Rectum 2006; 49: 939–944. Copyright
© 2006. All rights reserved. American Society of Colon and Rectal
Surgeons.
19. Colonic Volvulus
A. Introduction/Historical Perspective
• Volvulus of the bowel refers to a twisting or torsion of the
intestine about its mesentery.
• Volvulus of the colon usually occurs in the sigmoid or cecum,
but may involve any segment of colon.
• In the United States, volvulus represents a rare cause of intestinal obstruction, encompassing less than 5% of large bowel
obstructions. However, worldwide it is a much more common
form of large bowel obstruction, representing more than 50%
of the cases in some countries.
• With widespread use of fl exible endoscopy, many authors have
reported successful detorsion and decompression of all forms
of colonic volvulus using the colonoscope or fl exible sigmoidoscope. Because of high recurrence rates, these endoscopic methods are currently recommended as defi nitive treatment only for
very high-risk individuals who are too ill to undergo surgery, and
as a temporizing measure until eventual surgery under more controlled conditions for all other patients.
• The differential diagnosis of colonic volvulus encompasses any
cause of colonic distention. This includes all of the mechanical
as well as the nonobstructive causes.
– Mechanical causes include colonic and extracolonic neo-
plasms, as well as benign entities such as diverticulitis
and infl ammatory bowel disease.
– Nonobstructive causes include colonic pseudo-obstruction
(Ogilvie’s syndrome), and various intraabdominal processes that may result in an intestinal paralysis.
D.E. Beck et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery, 409
DOI: 10.1007/978-0-387-73440-8_19, © Springer Science + Business Media, LLC 2009
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