Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage I a) to localized abscesses (stages I b and II), to free perforation with purulent (stage III) or feculent (stage IV) peritonitis. The planned therapy of colonic diverticulitis is very difficult because preoperative diagnosis is uncommon and the method of treatment is usually decided at the time of laparotomy. While there is a little debate about the best treatment for mild episodes, uncertainty persists about the optimal management for severe episodes and complicated diverticulitis

Arnaudov, Pl.

Bozhkov, V.

Chernopolsky, Pl.

Madjov, R.

Plachkov, I.

English

Varna Medical University Press: Journals

DIAGNOSTIC AND TREATMENT STRATEGY IN COMPLICATEDCOLON DIVERTICULITISPlachkov I, Pl. Arnaudov, V. Bozhkov, Pl. Chernopolsky, R. MadjovSecond department of Surgery, UMHAT ”St. Marina” – MU- VarnaABSTRACTAcute di ver tic u li tis is a dis ease with a wide clin i cal spec trum, rang ing from a phlegmon (stage I a) to lo cal izedab scesses (stages I b and II), to free per fo ra tion with pu ru lent (stage III) or feculent (stage IV) peri to ni tis. Theplanned ther apy of co lonic di ver tic u li tis is very dif fi cult be cause pre op er a tive di ag no sis is un com mon and themethod of treat ment is usu ally de cided at the time of laparotomy. While there is a lit tle de bate about the besttreat ment for mild ep i sodes, un cer tainty per sists about the op ti mal man age ment for se vere ep i sodes and com -pli cated di ver tic u li tis.Key words: complicated diverticulitis, Hartmann’s operation, Resection with primary anastomosisThe fre quency of co lonic diverticulosis slowly in creases inlast two de cades. Diverticular dis ease is com mon in theWest ern world and is seen in more than 50% of peo ple over the age of 60 years and in 80 % of peo ple over the age of 80(1). Com pli cated diverticular dis ease is de fined as di ver tic -u li tis - it de vel ops in 20 % of peo ple with co lonicdiverticulosis. About 25 % of pa tients un der gone sur gi calin ter ven tion. Costs for the treat ment of acute di ver tic u li tisare more than 2, 6 bil lion dol lars only in United States, most of them are spend for sur gi cal treat ment and post op er a tivecom pli ca tions (4). The sig moid co lon is most com monlyaf fected part of the co lon. Etiopathogenesis of co lonicdiverticulosis still re mains un clear, but some fac tors likeover weight, low-fi ber diet, co lon mi cro flora changes areim por tant. It has also been shown that veg e tar i ans lesscom monly de velop diverticulosis, also the dis ease is ex -tremely rare in ar eas such as Af rica. On the other side theheirs of the Af ri cans liv ing in North Amer ica are suf fer ingfrom diverticulosis as of ten as the other Amer i cans (3). Com pli cated di ver tic u li tis (CD) as so ci ated with 20-30 % of all cases of diverticulosis, re mains a sig nif i cant cause ofmor bid ity and mor tal ity in pa tients af flicted with this prob -lem in ad di tion to the con sid er able ex penses for the treat -ment of the dis ease. Diverticulosis usu ally pres ent withtyp i cal triad of symp toms - sharp pain, of ten lo cated at aspe cific point of the ab do men, fe ver and leukocytosis, alsonau sea, vom it ing, con sti pa tion and di ar rhoea, blood in thefae ces, disuria. Clin i cal clas si fi ca tion of Eu ro pean as so ci a tion of en do -scopic sur geons is in tro duced in ta ble 1:The Hinchey clas si fi ca tion has tra di tion ally been used todis tin guish four stages of acute di ver tic u li tis. Type I and IIre late to in flam ma tory stages of the dis ease – phlegmon and lo cal ized ab scess, while type III(fig.3,4) and IV re late to de -vel op ment of pu ru lent re spec tively feculent peri to ni tis.This clas si fi ca tion has been mod i fied many times later(table2).Ta ble 1.Clin i cal clas si fi ca tion of Eu ro pean as so ci a tionof en do scopic sur geons (S. Soumian, 2008)Clinical classification of European association ofendoscopic surgeons stage Clinic SymptomsІNoncomplicateddiverticulosisFever, abdominal pain,CT data for diverticulosisІІReccurentdiverticulosisFrequent fever,$$Frequent abdominal painІІІComplicateddiverticulosisGIT bleedingPhlegmonAbscessPerforation- purulent or fecal peritonitisStricturafistulaBowel obstruction413Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, VarnaTable.2 Modified by Wasvery Hinchey classification ofcomplicated diverticulitis (S.Soumian, 2008)Modified Hinchey classification0 Mild clinical diverticulitisІ Confined pericolic inflammation - phlegmonІb Confined pericolic abscessІІPelvic, distant intraabdominal or retroperitonealabscessІІІ Generalized purulent peritonitisІV Fecal peritonitisFistula Colo-vesical/vaginal/enteric/cutaneousObstruction Large and/or small bowel obstructionIn di ca tions for planned sur gi cal in ter ven tion of di ver tic u li -tis change with the years. In the past the need to per form apro phy lac tic elec tive re sec tion was ad mit ted af ter two ep i -sodes of clin i cal pre sen ta tion of non com pli cated di ver tic u -li tis. This rec om men da tion is based on the as sump tion thataf ter two at tacks it is long odds for new ones, so there is anin creased risk for com pli ca tions in clud ing per fo ra tion andgen er al ized peri to ni tis (5). It claims that sur gi cal treat mentwill avoid com pli ca tion of di ver tic u li tis. New stud ies pre -tend that a sur gi cal re sec tion should be per formed af terthree or four doc u mented re cur rences of non com pli cateddi ver tic u li tis (6).Ac cord ing to Amer i can as so ci a tion for treat ment of co lonand rec tum dis ease from 2006 the num ber of the clin i cal re -cur rences of non com pli cated di ver tic u li tis is not a sig nif i -cant fac tor for sur gi cal treat ment (4). The causes for this se -ri ous change in sur geons ap proach to the dis ease are thenew treat ment meth ods – CT guided drain age and la vageor lap aro scopic one. Treat ment op tions for stages I b and IIstart from CT guided drain age to sur gi cal re sec tion ifneeded, bas ing on the pro gres sion of the dis ease, markedby clin i cal and lab o ra tory tests.It is im por tant to make ref er ence that in these cases the mor -tal ity is about 5-10 %, reach ing to 25 % in cases with ur gent sur gi cal in ter ven tion.The clin i cal as sess ment of the pa tients with acute di ver tic u -li tis is the best in di ca tor to es tab lish the need of emer gencyop er a tion. At the same time with get ting the med i cal his tory and pa tient’s gen eral con di tion, im me di ate pre op er a tivepro ce dures should be done – an ap pro pri ate an ti bi otic, bal -ance the blood ves sels vol ume, hypotony and in tox i ca tion.Di ag nos tic meth ods can be re duced to ab do men X-ray ra -di og ra phy, which can con firm the pres ence ofpneumoperitoneum or large bowel ob struc tion (fig.1).Even though CT us ing p.o. or i.v. con trast re mains best di -ag nos tic method with low level of fake re sults (fig.2). Inmost clin i cal cases this is best method for as sump tion thegrav ity of the dis ease and gives op por tu nity of choos ing the ap pro pri ate treat ment strat egy for each pa tient.URGENT SURGICALINTERVENTIONSHartmann’s op er a tion (HO) – the sur gi cal treat ment of CDde pends on: stage of the in flam ma tion be fore the op er a tion, pa tient gen eral con di tion, com pli ca tions and sur geon’s ex -pe ri ence. Most pa tients un der went ur gent sur gi cal in ter -ven tion are in stages III and IV – pu ru lent or feculent peri -to ni tis. Usu ally a Hartmann’s op er a tion is done, which isgolden stan dard for this stage of CD. This op er a tion is de -scribed by Anri Hartmann in 1923, who used it in treat ment of ob struc tive large bowel can cer. Last stud ies for the pa -tients un der went Hartmann’s op er a tion show sig nif i cantcom pli ca tions, in clud ing wound in fec tion to 29%, in suf fi -ciency of the anas to mo sis at the sec ond part of the op er a -tion – more than 25% and re spec tively again stoma, highmor tal ity – 15-25%. Ex cept this about in 35-40% of pa -414Fig.1 Contrast pours out from perforation of diverticulaFig.2 CT - a pericolic abscess from perforateddiverticulatients with stoma can not be made anas to mo sis, which leads to al ter na tive op er a tive meth ods for re duc ing post op er a tivecom pli ca tions and mor tal ity and in creas ing qual ity of life(8).Re sec tion with pri mary anas to mo sis (RPA) – one-stage op -er a tion for co lon re sec tion is be com ing an ad mit ted al ter na -tive of HO in treat ment of CD. It is pre sented for the firsttime by Velding in 1957, ac com plished in three pa tientswith peri to ni tis caused by di ver tic u li tis, with out in suf fi -ciency of the anas to mo sis. RPA be come pop u lar af ter itssuc cess ful us ing in large bowel pen e trat ing in ju ries. Fol -low ing cases with RPA, with or with out pro tec tive stomaand intraoperative la vage are pre sented as suc cess ful intreat ment of CD and are con fessed many ad van tages of themethod. Re sec tion with pri mary anas to mo sis saves tech ni -cal dif fi cul ties in re cov er ing bowel in teg rity, re duce ad di -tional ex penses and hos pi tal stay and do not al low dis tur -bance of pres ence of stoma (7).The de ci sion of do ing a RPA, RPA with pro tec tive stomaor HO is based on multidisciplinary, pro spec tive, ran dom -ized stud ies; this de ci sion is still sub jec tive and de pends onsur geon as sump tion of the op er a tion risk.Lap aro scopic la vage – a large num ber of stud ies pres entvery good re sults of us ing lap aro scopic la vage in treat mentof acute di ver tic u li tis. This pro ce dure is first de scribed be -fore more than 12 years and is done with 4 lit ters warmphys i o log i cal so lu tion, fol lowed by fix a tion of а 2 drain -age.This method leads to good re sults – low mor bid ity(4%) and mor tal ity (3%). The def i ni tion of the ap pro pri atefor these pro ce dure pa tients is still in di vid ual and there areno gen er ally ac cepted in di ca tions and con tra in di ca tions.This sur gi cal in ter ven tion can be op ti mally used in rel a -tively healthy and clin i cally sta ble pa tients (8). It can serveas use ful in ter ven tion for de creas ing the grav ity of the dis -ease or as a tran si tion to a rad i cal sur gi cal in ter ven tion.CONCLUSIONSThe op por tu ni ties for choos ing a sur gi cal strat egy in thetreat ment of CD are still in creas ing. Better un der stand ingcom plex ity of the dis ease is the base, on which the sur gi calstrat egy is de vel op ing.It is nec es sary to cre ate a model for risk as sump tion incolorectal op er a tions, which can serve as method for stan -dard ize the pre op er a tive risk in re la tion of de creas ing mor -bid ity and mor tal ity and fol low ing choice of op er a tivemethod.REFERENCES1. Comparato G, Di Mario F., NDSG Re cur rent di ver tic u li -tis. J Clin Gastroenterol. 2008;42(10):1130–1134.2. Munson K D, Hensien M A, Ja cob L N, Rob in son AM, Liston W A. Di ver tic u li tis. A com pre hen sive fol -low-up. Dis Co lon Rec tum. 1996;39(3):318–322.3. Wong W D, Wexner S D, Low ry A, et al. The Amer i -can So ci ety of Co lon and Rec tal Sur geons Prac ticepa ram e ters for the treat ment of sig moid di ver tic u li -tis—sup port ing doc u men ta tion. The Stan dards TaskForce. Dis Co lon Rec tum. 2000;43(3):290–297.4. Etzioni D A, Mack T M, Beart R W, Jr, Kai ser A M.Di ver tic u li tis in the United States: 1998-2005: chang -ing pat terns of dis ease and treat ment. Ann Surg.2009;249(2):210–217.5. Abbas S. Re sec tion and pri mary anas to mo sis in acutecom pli cated di ver tic u li tis, a sys tem atic re view of thelit er a ture. Int J Colorectal Dis. 2007;22(4):351–357.6. Martel J, Raskin J B., NDSG His tory, in ci dence, andep i de mi ol ogy of diverticulosis. J Clin Gastroenterol.2008;42(10):1125–1127.7. Sandler R S, Everhart J E, Donowitz M, et al. Thebur den of se lected di ges tive dis eases in the UnitedStates. Gastroenterology. 2002;122(5):1500–1511.8. Schil ling M K, Mau rer C A, Kollmar O, Bьchler M W.Pri mary vs. sec ond ary anas to mo sis af ter sig moid co lonre sec tion for per fo rated di ver tic u li tis (Hinchey stage IIIand IV): a pro spec tive out come and cost anal y sis. DisCo lon Rec tum. 2001;44(5):699–703. dis cus sion703–705.415Scripta Scientifica Medica, 2011; vol. 43 (5) Copyright © Med i cal Uni ver sity, VarnaFig.3 Colon resection with acute diverticulitis-HincheyIIIFig.4 Multiply diverticula with complicateddiverticulitis - Hinchey III

Diagnostic and treatment strategy in complicated colon diverticulitis

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Diagnostic and treatment strategy in complicated colon diverticulitis

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