DISMINUYENDO EL USO DE OSTOMÍAS
EN LA DIVERTICULITIS
Dr. Stanley Goldberg
Introduction
The presence of Colonic diverticulae in older patients is a common finding. As
the percentage of older Americans increases, it is likely that the surgeon will
likewise more frequently encounter both uncomplicated and complicated
diverticulitis. Furthermore, as new approaches are described and refined both
for nonoperative and operative treatment, it is imperative that surgeons
continuously reassess the evaluation and care of diverticulitis patients. This
presentation discusses current approaches to the diagnosis, work-up and
treatment of diverticulitis, with a special focus on perforated sigmoid diverticular
disease.
Diagnosis
The initial diagnosis of uncomplicated diverticulitis is usually fairly
straightforward based on patient history, physical examination, and laboratory
studies. The use of CT scan in every patient suspected of having diverticulitis
has been proposed, but such an approach is not cost-conscious, nor is it
necessary for patients with uncomplicated diverticulitis. We obtain a CT scan
when the patient shows no clinical improvement after 24-48 hours of medical
treatment, if there is clinical deterioration, or if a pelvic abscess is suspected at
initial presentation.
If the patient appears to have uncomplicated diverticulitis and responds
appropriately to medical treatment, a CT scan is unnecessary. In such cases
(when diverticulae have never been demonstrated) an enema contrast study
should be performed four to six weeks after recovery to confirm the presence of
diverticulae. Furthermore, contrast enema imaging can be useful in evaluating
the extent of the disease, thus aiding in decisions concerning the advisability of
elective resection. Finally, contrast enema may also indicate to rule-out a
neoplastic process.
Non-Surgical Management
Medical management consists of bowel rest, frequent reevaluations by the
physician, and intravenous antibiotics. Regimens should be aimed at gram
negative aerobes as well as anaerobes, especially Bacteroides species.
Duration of antibiotic treatment is based on clinical response and usually lasts
five to seven days in cases of uncomplicated diverticulitis. We believe that a
patient who is improved to the point of discharge does not require further oral
antibiotic therapy.
Percutaneous drainage techniques have significantly altered the approach to
the patient with a diverticular abscess.
The only contraindications to
percutaneous drainage are an abscess, which is inaccessible, pathology which
is inappropriate (primarily phlegmonous), a patient who is too high-risk
(coagulopathy), and cases which require emergent surgical intervention
irrespective of the presence of the abscess (peritonitis). We percutaneously
drain intra-abdominal and pelvic abscesses in all other stable patients.
Catheter management is aimed at complete drainage of the abscess cavity and
prevention of drain plugging. Sterile irrigation is gently used to unclog the
catheter every six to eight hours and as needed. Multiple catheters may be
required. There is controversy concerning the need and timing of further
imaging studies following catheter placement. A repeat CT scan is obtained if
the patient fails to improve clinically after catheter placement search for
evidence of incomplete drainage or an undrained abscess. Controversy also
surrounds the question of duration of drainage. If the patient displays the
appropriate clinical improvement and the catheter drainage is minimal,
fistulogram is performed with water-soluble contrast via the catheter. If no
identifiable cavity remains, even in the presence of a demonstrable fistula to the
colon, the catheter is removed. Clinically stable patients who continue to have
moderate catheter drainage are sent home on oral antibiotics. When their
drainage subsides, they undergo fistulogram and follow-up as described.
Elective Resection
Perhaps the greatest area of controversy concerns the indications for elective
resection following resolution of diverticulitis treated medically. In agreement
with the majority of authors, we recommend surgical resection of the involved
segment in patients who have suffered two or more documented attacks of
uncomplicated diverticulitis. Likewise, elective resection should be performed
following one attach of documented uncomplicated diverticulitis in patients who
require chronic immunosuppression. In ability to distinguish diverticular disease
from malignancy also clearly requires resection. Finally, colovesicular and
colovaginal fistulae rarely close with conservative therapy, and the presence of
either is an indication for surgical resection. Our approach to elective resection
differs from that of many authors in regards to the following three groups of
patients.
Elective Resection Following Successful Precutaneous Drainage
We do not automatically recommend elective resection in every patient whose
first bout of diverticulitis is complicated by an abscess if that abscess is
successfully drained and the inflammation resolves. Four to six weeks following
catheter removal, a contrast study and/or endoscopic exam is performed. As
described above, findings on these studies help determine the need for elective
resection.
Elective Resection in the Immunocompromised Patient
For patients who require long-term immunosuppression and are known to have
diverticulosis but have no history of diverticulitis, some authors advocate
elective, prophylactic sigmoid resection. We disagree, as it has not been
conclusively demonstrated that a significant portion of these patients will
develop diverticulitis, and subjective all such immunocompromised patients to a
major operation is not without risk. Of course we recognize that diverticulitis is
more difficult to diagnose and rarely if ever responds to conservative treatment
in this patient group. Thus, a high index of suspicion and an aggressive
treatment approach is necessary in the immunocompromised patient with
diverticulitis.
Surgical Options in Perforated Sigmoid Diverticular Disease
The Hartmann procedure is the only operative approach we recommend in
patients with perforated diverticulitis and feculent peritonitis. In the vast majority
of patients with perforated diverticulitis and purulent peritonitis, we likewise
utilize the Hartmann procedure. However, in a small subset of such patients
(stable patients, minimal peritonitis, early exploration), resection (with or without
intraoperative lavage), primary anastomosis, and creation of a diverting splitloop ileostomy is acceptable. Such an approach allows for a simpler and safer
split-loop ileostomy takedown, avoiding the significant morbidity of colostomy
takedown and reanastomosis following a Hartmann procedure. When an
abscess is inadvertently entered during exploration of a patient without
peritonitis, resection and primary anastomosis with or without the creation of a
diverting split-loop ileostomy is indicated. Finally, patients with abscesses that
can be removed en bloc without spillage, should undergo resection and primary
anastomosis without diversion.
Extent of Resection
The entire distal sigmoid colon must be resected, leaving only proximal rectum
for performance of anastomosis or pouch closure, as resection proximal to
rectum has been demonstrated to have a higher rate of recurrent diverticulitis in
the sigmoid remnant. The proximal extent of resection, on the other hand, is
not defined anatomically. Proximally the colon should be divided where the
bowel is soft, even in the presence of diverticulae. The area of resection may
be so limited that mobilization of the splenic flexure is unnecessary.
Summary
There are many controversies concerning the treatment of diverticulitis in
patients, which would best be resolved by prospective studies. Percutaneous
drainage of abscesses now allows an increasing number of diverticulitis patients
to be successfully treated without operation. We believe that a significant
number of such patients may not require subsequent elective resection.
Likewise, not all younger patients require elective resection following resolution
of their first attack of diverticulitis. Nor does prophylactic resection seem wise in
all immunocompromised diverticulosis patients without an inflammatory history.
Finally, the role of resection with primary anastomosis, both with and without
loop diversion, continues to expand.
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