Management of Complicated Diverticulitis

Historical Perspective

Diverticulosis is a common problem in developed countries. Its incidence increases with age, ranging from 30% to 50% in individuals older than 50 years and more than 65% in those older than 80 years. One fourth (25%) will develop ‘‘complicated diverticular disease,’’ defined as diverticulitis associated with phlegmon, abscess, fistula, stricture presenting with obstruction, or perforation with peritonitis. There is surprisingly little high-grade evidence on which to draw firm recommendations. Most of what we know comes from retrospective case series dating back more than 100 years.¹ The first resection for perforated diverticulitis with peritonitis was by Mayo et al.² in 1907. However, in a subsequent report from the Mayo clinic in 1924, Judd and Pollock³ concluded that primary resection was too difficult in the acute setting, and stirring up the infection resulted in a very high mortality. This was in the preantibi+otic era, and their suggested procedure was a colostomy with irrigation of the distal colon and then delayed resection as the patient tolerated. In 1942, Smithwick⁴ reported the Massachusetts General Hospital experience comparing different operations that had been performed at that institution, and he concluded that the best early mortality and long-term outcomes were achieved with preliminary proximal colostomy and then resection in 3 to 6 months after the inflammation had resolved. The three-stage procedure then became the standard of care. The first operation was a diverting transverse colostomy and drainage. The second operation (performed 3 to 6 months later) was definitive resection and colostomy. The third operation (performed 3 to 6 months after the second) was colostomy closure. Starting in the late 1950s, a case series emerged that demonstrated, with the advent of preoperative antibiotics, that in select cases, the diseased colon could be safely resected. In 1984, Krukowski andMatheson⁵ reviewed the mortality in 36 case series published from 1957 to 1984 that had compared the use of resection versus colostomy with no resection. These reports included 821 cases of diverticulitis with purulent or fecal peritonitis, of which 316 patients underwent acute resection with a mortality rate of 12% compared with a mortality rate of 29% in the 505 patients who underwent colostomy with no resection. Of course, these case series suffer from selection bias in that healthier patientswere more likely to undergo acute resection and the less healthy were more likely to receive a colostomy. However, this report did show that, with antibiotics and better supportive care, a substantial portion of patients can undergo acute resectionwith amore acceptablemortality rate. In addition, advocates argued that acute resection avoids missing a colon cancer (which occurred in 2-7% of the cases) and decreases morbidity because up to 20% of the nonresected patients will ultimately develop a fistula. Interestingly, there are two prospective randomized controlled trials comparing acute resection with colostomy for perforated sigmoid diverticulitis that show divergent results. In a single-center study from Denmark published in 1993, 62 patients were operated on for peritonitis secondary to diverticulitis, and of those, 46 patientswere found to have Hinchey III purulent peritonitis (i.e., no hole in the colon)^.6 Twenty-one were randomized to colostomy with no resection, and all survived. Of the 25 patients randomized to acute resection, six (24%) died. In contrast, a 2000 report of a multicenter French prospective randomized controlled trial included 103 patients with (Hinchey III) purulent and (Hinchey IV) fecal peritonitis.⁷ Forty-eight of these patients were randomized to colostomy (with suture closure of the hole in the colon for the HincheyI V cases).Their postoperative peritonitis rate was high at 20%, with a mortality rate of 18%. In contrast, in the 55 patients randomized to acute resection, the postoperative peritonitis rate was significantly lower at less than 2%, and they had a similar mortality rate of 23%. In 2000, the American Society of Colon and Rectal Surgeons revised their practice parameters for treatment of sigmoid diverticulitis.⁸ Based on their expert review of the data, they concluded that for perforated diverticulitis with peritonitis, the procedure of choice was a segmented resection with end colostomy (i.e., a Hartman procedure). However, in 2006, Constantinides et al.⁹ published a systematic review of 15 comparative studies (13 retrospective, 2 prospective nonrandomized) published from 1984 to 2004 that compared primary resection with anastomosis (PRA) with that of the Hartman’s procedure (HP) for emergency surgery for acute diverticulitis. The meta-analysis of these data showed that for the subgroups with diverticular disease with abscess and diverticular disease requiring an emergency operation, mortality was improved in those patients who underwent PRA compared with that in those who underwent the HP. In addition, for surgical complications (including wound infections, abscesses, and peritonitis), there was a trend toward improved outcomes favoring PRA over the HP. Again, this review of primarily retrospective case series suffers from selection bias, where the healthier people undergo PRA and the not so healthy receive a colostomy.  However, what these data do show is that (1) emergency PRA in select patients has a low rate of anastomotic leak rate of roughly 6%; (2) PRA and the HP had similar operative times; and (3) for the sicker patients (Hinchey 9 II subset), PRA and the HP had equivalent mortality (14.1 vs. 14.4%). As a result of these emerging data, in 2006, the American Society of Colon and Rectal Surgeons updated their practice parameters for sigmoid diverticulitis.¹⁰ They concluded that urgent sigmoid resection is required for perforated diverticulitis with peritonitis, and the alternatives to the HP include primary anastomosis with or without interoperative lavage, and the precise role of primary anastomosis (especially without diversion) remains unsettled. Interestingly, as the American Society of Colon and Rectal Surgeons has been endorsing an increasingly more aggressive approach, there have been at least 11 case series with more than 301 patients since 1996 that document surprisingly good results with laparoscopic lavage and drainage.¹¹ In 2008, Myers et al.¹² reported the best series to date. Of 1,257 patients admitted for diverticulitis within 7 years, 100 (7%) had peritonitis, with evidence of free air on roentgenogram or computerized tomographic (CT) scan. These patients were resuscitated, given a third-generation cephalosporin and flagyl, and then taken emergently to the operating room (OR) for laparoscopy. Of the 100 patients who underwent laparoscopy, eight were found to have Hinchey IV disease and underwent the HP. The remaining 92 Hinchey II and III patients underwent lavage and drainage. Three of these patients died (much lower than reported for PRA or the HP). An additional two patients had nonresolution, one went on to have the HP performed, and the other one had further percutaneous drainage. Overall, 88 of the 92 lavage patients had resolution of their symptoms. They were discharged to home and were not offered a delayed definitive resection. During the 36 months of follow-up, there were only two recurrences. This series challenges our basic understanding of the natural history of diverticulitis. It is surmised with resolution of an acute perforation; local fibrosis prevents the recurrent perforation of the diverticulum. Given this information, it is time to rethink how we care for these very difficult patients.^13-15 The purpose of this article is to provide a practice algorithm for acute care surgeons to use and frame research questions (Fig. 1).