Management of Complicated Diverticulitis

Annotation for Point J

DEFINITIVE RESECTION

This requires mobilization of the sigmoid colon with avoidance of injury to the ureters. Ureteral stents should be used selectively in those patients with abscesses or excessive inflammation in the pelvis. The distal margin of resection should be the upper rectum, whereas the proximal margin of resection should go back to the noninflamed descending colon. All diverticuli do not need to be resected. The splenic flexure is generally not mobilized. As discussed in the Historical Perspective, the major current debate is whether to perform a PRA or to perform the HP. Another unresolved debate is if a PRA is performed, should a protecting diverting ileostomy be added? Unless conditions are optimal, this is the prudent thing to do. The use of perioperative colonic lavage seems to lower complications with PRA, but the supporting evidence is limited. Omentoplasty does not offer any benefits. For patients who have undergone limited resection in a previous DCL and are returning for their second operation, a definitive resection should be done if feasible. Then the debate is whether to do primary anastomosis. There are limited data in the diverticulitis literature on which to make this decision. In the trauma literature, the results of delayed colon anastomosis are quite variable, with anastomotic leak rates varying between 12% and 30%.^33–35  Again, this decision is individualized based on presenting physiology, the condition of the bowel, patient comorbidities, surgeon experience, and hospital factors.