When surgery is indicated for patients with diverticulitis?

Diverticular disease of the colon is a consequence of the herniation of the mucosa that internally coats the large intestine between the muscular fibers of the muscular wall. Diverticular diseases of the bowel (diverticulitis and diverticulosis) were rare until the end of the 19th century and are now epidemic in Western countries.

When the patient does not respond to conservative clinical measures or their condition is deteriorating, surgical intervention is required urgent.

At age 60, the risk of developing diverticular disease is 50%, but no more than 10% will present symptoms, and a smaller portion will still require surgery. Increased incidence is mainly due to a drastic reduction in dietary fiber intake.

Acute diverticulitis is a complication of diverticular disease resulting from an infectious and inflammatory process that begins within the diverticulum.

In which cases surgery for diverticulitis is indicated?

When the patient does not respond to conservative clinical measures or their condition is deteriorating, urgent surgical intervention is required. However, patients with localized acute pain and diverticulitis, without signs and symptoms suggestive of impairment of their systemic condition, may be treated without hospital admission.

If there is no improvement in symptoms, hospitalization is recommended. Persisting of the symptoms, new radiological examinations are necessary in order to evaluate possible complications - such as free perforation of the intestine, abscesses, generalized peritonitis and fistulas. In these cases, surgery is indicated on localized abscesses that have not responded to drainage guided by radiology, pelvic or intraabdominal abscesses, pneumoperitoneum (free air into the abdomen), and generalized peritonitis (abdominal infection). intestine with organs such as the bladder, vagina and ureter, which also requires surgical treatment.

The decision to surgically intervene in patients with uncomplicated, or electively, diverticulitis is a controversial subject. It is usually accepted in cases of young patients (less than 50 years old) with obstructive signs, fistulas and chronic pain of difficult resolution.

Immunocompromised patients should be operated after the first uncomplicated crisis to avoid a second complicated crisis

When surgery for diverticulitis is not indicated?

Surgery for diverticulitis is not indicated:

if the acute diverticulitis crisis is uncomplicated

• when the patient is well from the systemic point of view and responds to conservative clinical measures
• if the acute diverticulitis crisis is complicated, with localized abscesses that respond to radiologically guided percutaneous drainage
• patients without clinical conditions to tolerate surgery, however simple and rapid it may be
• Surgical options

Surgery may be via the open and laparoscopic pathways, where the affected and most often resected portion is the sigmoid colon. The most frequent surgical modalities in the complicated acute diverticulitis crisis are:

1. Resection and primary anastomosis (surgery at one time): Surgery has been chosen in recent years, since the studies show a lower morbidity rate.

2. Hartmann surgery (two-stage surgery): The sigmoid is squeezed, the rectum is closed, and a colostomy is made with the descending or transverse colon. Closing the colostomy, attaching the colon to the rectum occurs three months after the first surgery.

3. Sigmoidectomy and primary anastomosis with protective ileostomy: an interesting option because it distorts intestinal transit of the anastomosis with an ileostomy pocket, which is much easier to close than Hartmann's surgery, reducing complications in the case of opening the connection of the colon with the rectum.

In elective surgery (outside the period of severe complicated diverticulitis), resection with primary anastomosis is always performed.

The greatest risk in performing surgery for diverticulitis is always dehiscence of the anastomosis (junction of the rectum with the colon through sutures mechanical or manual). This condition implies leakage of fecal contents into the abdominal cavity, often treated with new surgery, with high morbidity. In addition, the risks are like those of surgeries in general.

When surgery is indicated for patients with diverticulitis?

Diverticular disease of the colon is a consequence of the herniation of the mucosa that internally coats the large intestine between the muscular fibers of the muscular wall. Diverticular diseases of the bowel (diverticulitis and diverticulosis) were rare until the end of the 19th century and are now epidemic in Western countries.

(Health)

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