Our Summary

The way doctors treat Diverticular Disease, a condition that affects the colon, has changed significantly in the last 20 years. This paper looks at the latest methods for surgical treatment of one type of this disease, called sigmoid diverticulitis. In the past, the most common reason for removing part of the colon was due to cancer, but in the last decade, acute diverticulitis has become the leading cause. However, now surgery is less common even in emergency cases.

Currently, if the disease isn’t too severe, doctors usually manage it with medicine rather than surgery. Even if the disease is more serious and causes an abscess, or a pocket of infection, in the abdomen, non-surgical treatment is still often possible.

If a patient is very ill with a serious infection that affects the whole body (severe sepsis or septic shock), the first step is to stabilize them by replenishing their body fluids. Whether or not to do emergency surgery depends on how the patient responds to this treatment. If the patient is stable, a minimally invasive surgical procedure using a laparoscope is the preferred choice. This approach has been shown to have fewer complications after surgery.

A procedure known as Hartmann’s procedure, which involves removing a diseased section of the colon and creating a temporary opening (stoma) in the abdomen, is now only used in certain severe cases. Some doctors suggest a less invasive procedure, known as laparoscopic peritoneal lavage, as either a temporary measure before surgery or as a definitive treatment that does not involve removing part of the colon. If a patient is not responding to fluid treatment and is unstable, a type of emergency surgery called damage control surgery may be more beneficial than Hartmann’s procedure. This approach is often associated with a high rate of success in restoring normal function of the colon.

FAQs

  1. What is the current state-of-the-art surgery for sigmoid diverticulitis?
  2. What factors guide the decision for emergency surgical approach in patients with severe sepsis or septic shock due to diverticulitis?
  3. How has the indication for surgical resection in treating diverticulitis changed over the past two decades?

Doctor’s Tip

A helpful tip a doctor might tell a patient about diverticulitis surgery is to follow post-operative care instructions carefully, including taking prescribed medications, avoiding strenuous activities, and eating a high-fiber diet to prevent future flare-ups. It is important to attend follow-up appointments with your healthcare provider to monitor your recovery and address any concerns.

Suitable For

Patients who are typically recommended diverticulitis surgery include those with severe abdominal infective complications, severe sepsis or septic shock, severe generalized peritonitis with metabolic derangement, and severely ill patients. Emergency surgery may be indicated in these cases. Additionally, patients who do not respond to conservative medical treatment for uncomplicated diverticulitis or complicated diverticulitis with abdominal abscess may also be recommended for surgery. Surgeons with advanced laparoscopic skills may prefer a laparoscopic approach for these patients, as it is associated with lower postoperative complication rates. In cases of hemodynamic instability not responding to fluid resuscitation, initial damage control surgery may be considered as an alternative to a Hartmann’s procedure, with a high rate of primary anastomosis.

Timeline

  • Before diverticulitis surgery:
  1. Patient presents with symptoms of diverticulitis, such as abdominal pain, fever, and changes in bowel habits.
  2. Diagnosis is confirmed through imaging tests, such as CT scans or colonoscopy.
  3. Patient may undergo conservative medical treatment, such as antibiotics and dietary changes, for uncomplicated diverticulitis.
  4. In cases of complicated diverticulitis with abscess, non-operative management may be considered.
  5. In severe cases with hemodynamic instability, emergency surgery may be needed.
  • After diverticulitis surgery:
  1. Laparoscopic surgery is the preferred approach for hemodynamically stable patients, with lower postoperative complication rates.
  2. Hartmann’s procedure is indicated in cases of severe peritonitis or severely ill patients.
  3. Laparoscopic peritoneal lavage may be considered as a bridge to surgery or definitive treatment without colonic resection in selected patients.
  4. Damage control surgery is preferred over Hartmann’s procedure in cases of hemodynamic instability not responding to fluid resuscitation.
  5. Primary anastomosis may be performed in some cases, leading to better outcomes for the patient.

What to Ask Your Doctor

  1. What are the reasons for recommending surgery for diverticulitis in my case?
  2. What are the potential risks and complications associated with the surgery?
  3. What is the expected recovery time after the surgery?
  4. Will I need a colostomy bag after the surgery?
  5. What are the alternative treatment options to surgery for diverticulitis?
  6. How many times have you performed this type of surgery for diverticulitis?
  7. What is your success rate with this type of surgery?
  8. Will I need any special dietary or lifestyle changes after the surgery?
  9. How long will I need to stay in the hospital after the surgery?
  10. Are there any long-term effects or complications I should be aware of after the surgery?

Reference

Authors: Cirocchi R, Sapienza P, Anania G, Binda GA, Avenia S, di Saverio S, Tebala GD, Zago M, Donini A, Mingoli A, Nascimbeni R. Journal: Langenbecks Arch Surg. 2022 Feb;407(1):1-14. doi: 10.1007/s00423-021-02288-5. Epub 2021 Sep 23. PMID: 34557938